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OF 

THE  UNIVERSITY 

OF  CALIFORNIA 

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OF 

Cooper  Medical  College 

Date ,.2^.jJ^.<.^..C.    /j/^^^^^^ 

No ':^..^-S^...2-.  Class /..6Z. 


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A  TONIC. 


HORSFORD'S  ACID  PHOSPHATE 

Prepared  under  the  direction  of  Prof.  E.  N.  Horsford. 


A  most  excellent  and  agreeable  tonic  and  appetizer.     It 
nourishes  and  invigorates  the  tired  brain  and  body,  imparts 
renewed  energy  and  vitality,  and  enlivens  the  functions. 
Dr.  Ephraim  Bateman,  Cedarville,  N.  J.,  says: 

"  I  have  used  it  for  several  years,  not  only  in  my  practice, 
but  in  my  own  individual  case,  and  consider  it  under  all  cir- 
cumstances one  of  the  best  nerve  tonics  that  we  possess.  For 
mental  exhaustion  or  overwork  it  gives  renewed  strength  and 
vigor  to  the  entire  system." 


Descriptive  pamphlet  free. 

RUMFORD  CHEMICAL  WORKS, 

PROVIDENCE,  R.  I. 


Beware  of  Substitutes  and  Imitations. 

CAUTION:— Be  sure  the  tvord  " Horsford 's  "  is  printed  on  t7i9  label. 
All  others  are  spurious.    Never  sold  in  bulk. 


THE  USES  OF  WATER 

IN  MODERN   MEDICINE. 


BY 


SIMON  BARUCH,  M.  D., 

Attending  Physician  to  the  Manhattan  Ge7ieral  Hospital  and  New  York 
Juvenile  Asylum  ;   Consulting  Physician  to  the  Montefiore  Home  for 
Chronic  Invalids';  formerly  Chairman  of  the  Board  of  Health  of 
South  Carolina ;  Gyncecologist  to  the  Northeastern  Dispensary, 
and  Physician  for  Eye,  Ear,  and  Throat  to  the  Northwest- 
ern Dispensary  of  New  York ;  Member  of  the  New  York 
Academy  of  Medicine,  County  Medical  Society, 
and  Northwestern  Medical  and  Surgical  So- 
ciety of  New  York ;  Honorary  Member  of  the 
South  Carolina  Medical  Association. 


VOLUME    I. 


GEORGE    S.  DAVIS, 

DETROIT,   MICH. 


Copyrighted  by 

GEORGE  S.  DAVIS. 

1892. 


Biomedieal 
Ubnry 

szo 

1/:/ 


TO 

DR    WILHELM   WINTERNITZ, 

PROFESSOR   OF  HYDROTHERAPY   IN  THE  VIENNA  UNIVERSITY, 

The  Father  of   Modern   Hydrotherapy, 

THIS  WORK  IS   DEDICATED 

BY   THE   AUTHOR, 

as  a  token  of   appreciation  of    the  hospitality  and  instruc- 
tion received  by  him  at  the  Institute 
in  Kaltenleutgeben. 


Rofi/nc; 


TABLE  OF  CONTENTS. 


PREFACE. 

Page. 
No  Other  Original  Work  in  the  English  Language — 
Author's  Indebtedness  to  Prof.  Winternitz — Hydro- 
therapy Severed  from  Hydropathy — Water  to  be 
Used  as  Any  Other  Remedial  Agent,  Not  to  be  En- 
tirely Substituted  for  the  Latter — Importance  of 
Recent  Pharmacological  Investigations — Distinction 
between  Hydrotherapy  and  Hydropathy — Definition 
of  Water  Cure — The  Subject  of  Water  to  be  Present- 
ed upon  a  Rational  Physiological  and  Clinical 
Basis xiii-xv 

CHAPTER   I. 

DEFINITION   AND    HISTORY. 

Definition  of  Hydrotherapy — Division  of  the  Subject — 
History — Water  an  Orthodox  Remedy  Since  the  Days 
of  Hippocrates,  Galen,  and  Celsus — Asclepiades — 
Alexander  of  Tralles — Paulus  ^gineta— Van  der 
Heyden — Floyer  of  England,  Pitcairn.  Cheyne,  Hux- 
ham — Friedrich  Hoffman— Wright,  Currie,  Joseph 
Franck,  Hufiand,  Priessnitz,  and  the  Empirics--Op- 
position  of  the  Paris  Academy  Overcome  by  Clinical 
Demonstration—  Bouilland  Convinced — Scontetten, 
Lubanski,  Fleury,  Duval,  Charcot — Modern  Fever 
Treatment — Ernst  Brand — Testimony  of  Niemeyer, 
Dujardin-Beaumetz,  Peter,  Erb  of  Heidelberg,  Sem- 
mola  of  Naples,  Hoffman  of  Leipzig,  Hiram  Corson 
of  Pennsylvania — History  Repeats  Itself — The  Best 
Men  Advocate  Water  in  All  Epochs — Therapeutic 
Nihilism  of  the  Moderns— Water  Again  Triumphant 


X. 

Page. 

under  Brand,  Juergenssen,  and  Ziemssen— Anti- 
pyresis  Misleads— Chemical  Antipyretics  Abused; 
Water  Suffers  in  Consequence— Fallacies  Exposed — 
New  Dangers — Naturarzte — Father  Kneippe — Insti- 
tute for  Naturheilkunde  at  Chemnitz,  Saxony — 
Good  Results  Obtained  by  these  Empirics  Warrant 
ISIore  Careful  Study  of  the  Subject  by  Physicians.  ..1-22 

CHAPTER  II. 

MODE   OF   ACTION    OF    WATER. 

Internal  Use — Effect  on  Pulse — Physiological  Investiga- 
tions of  Bocker — Effect  on  Tissue  Metamorphosis — 
Peristalsis— Biliary  Secretion — Clinical  Value  Dem- 
onstrated by  Meigs,  Cantani,  Debove — Abused  by 
the  Empirics — External  Use  of  Water — Water  as  an 
Agent  for  Absorbing  and  Giving  Off  Heat  and  Cold 
— Its  Physical  Flexibility — Effect  of  Temperatures — 
Limits — Special  Terminal  Nerve  Centres — Illustra- 
tion of  Reflex  Effect  in  Syncope — Anaesthesia — Dif- 
ference of  Effect  According  to  Duration — Influence  of 
Thermic  Application  upon  the  Circulation — Reaction 
— Hyperaemia  Not  from  Vascular  Paralysis — Effects 
upon  Distant  Parts — Prof.  Semmola's  Remarkable 
Clinical  Experience — Damage  Possible — Increased 
Blood-pressure  —  Sphygmographic  Evidence— Cold 
Enhances,  Heat  Lowers,  Vascular  Tone — Practical 
Deductions— Increased  Urination — Reflex  Effects — 
Naumann's  Experiments  on  Frogs — Max  Schiiller's 
Graphic  Demonstrations  on  Trephined  Rabbits — 
Practical  Deductions— Influence  of  Thermic  Appli- 
cations upon  the  Respiration— Montefiore  Home — 
Hot-air  Boxes — Influence  of  Thermic  Applications 
upon  Tissue  Change — Chiefly  on   Non-nitrogenous 


XI. 

Page. 
Matter — Increase  of  COg  and  O  Interchange — Prac- 
tical Deductions — Influence  of  Thermic  Applications 
upon  the  Body  Temperature— Local  Temperature 
Depends  on  Arterial  Blood  Supply — Peripheral  Cir- 
culation the  Chief  Element  in  Heat  Regulation — 
Compensatory  Action — Fallacies  Exposed — Differ- 
ence between  Mouth  and  Rectal  Temperature  After 
Cold  Baths — Reaction  Aimed  At  — Laws  of  Fleury 
and  Winternitz — Practical  Deductions — Summary- 
Mechanical  Irritation  a  Valuable  Aid  to  Baths — 
Rationale  of  Cooling — Experiments  in  Zunz  Labora-  " 
tory — Temperature  Changes  Depend  Chiefly  on  Heat 
Dissipation — Practical  Application  of  These  Truths. 23-70 

CHAPTER  III. 

TECHNIQUE    AND    CLINICAL    APPLICATION    OF    HYDROTHERAPY. 

Necessity  of  Precision — Illustrations  of  "  How  Not  to 
Do  It  " — Procedures  for  Local  Effects — Mechanical 
Influence  of  Water  in  Cavities — Emetic — Enema — 
Drinking  Hot  Water— Irrigation  in  Gastric  and  In- 
testinal Disturbances  of  Infants — Lavage  for  Diag- 
nosis and  Treatment — Technique  Detailed — Illus- 
trations— Gastric  Irrigation  for  Treatment — Lavage 
and  External  Hydrotherapy  Combined — Lavage — 
Dilatation  of  Stomach — Gastralgia — Intestinal  Ob- 
struction— Colic  from  Gall  Stones — Catarrhal  Jaun- 
dice— Dysentery — Lead  Colic — Water  in  Gynaecology 
— Dr.  Emmet's  Practice,  Illustrating  Importance  of 
Details — Water  in  Surgery — Old  and  New  Wound 
Treatments  Compared — Hot  Water  as  an  Antiseptic; 
as  a  Styptic — Contra-indications  to  the  Use  of  Water 
— Eczema — Otitis  Media — Normal  Puerperal  Condi- 
tion— Waler  Powerful  for  Evil  as  well  as  for  Good. 71-115 


PREFACE. 


That  the  proper  methods  of  applying  water  in  disease 
require  to  be  brought  before  the  American  medical  public 
in  a  comprehensive,  practical  form  has  long  been  the  author's 
observation.  He  has,  therefore,  undertaken  to  w^rite  a  suc- 
cinct account  of  the  present  status  of  water  as  a  therapeutic 
agent.  The  only  work  in  the  English  language  which  has 
not  the  taint  of  quackery,  the  valuable  treatise  of  Winternitz 
in  Ziemssen's  Handbook  of  Therapeutics,  has  long  been 
out  of  print.  Owing  to  its  being  a  portion  of  a  large  work, 
it  has  escaped  the  attention  of  the  profession,  and  has  not 
received  the  appreciation  it  deserves  as  a  scientific  exposition 
of  the  views  of  an  author  who  has  rendered  medicine  the 
incalculable  service  of  rescuing  the  remedial  virtues  of  water 
from  the  empirical  environment  into  which  it  had  fallen, 
and  to  which  the  medical  profession  appeared  until  recently 
to  be  inclined  to  abandon  it. 

As  Ziemssen  has  justly  said,  "  whatever  we  know  of 
hydrotherapy,  we  owe  to  Winternitz."  To  Prof.  Winternitz 
I  am  personally  indebted,  not  only  for  knowledge  derived 
from  his  numerous  scientific  and  clinical  writings,  each  one 
of  which  is  replete  with  logically  stated  truths,  but  also  for 
personal  guidance  and  instruction  during  a  sojourn  at  his 
institution  in  Kaltenleutgeben,  where  the  best  informed 
hydrotherapists  in  Europe  have  received  their  instruction. 

In  this  monograph  it  is  not  proposed  to  furnish  an  ex- 
position of  hydropathy  or  the  water-cure  system,  that 
method  of  treatment  whose  enthusiastic  followers  claim  that 
it  will  inaugurate  the  millennium   of  therapeutics,   because 


XIV. 

its  efficacy  is  not  less  marvelous  than  its  methods  are  simple 
and  easily  comprehended.  It  is  the  author's  purpose  to 
sever  hydrotherapy  frotn  any  connection  with  hydropathy  or  water- 
cure,  and  so  present  the  subject  that  the  general  practitioner 
may  avail  himself  of  the  former,  just  as  he  does  of  the 
medicinal  agents,  of  whose  action  he  really  is  capable  of 
learning  much  less. 

The  author  desires  to  emphasize  the  fact,  however,  that, 
while  he  recognizes  the  undoubted  value  of  water  as  a  thera- 
peutic agent,  he  is  not  prepared  to  substitute  it  for  all  other 
therapeutic  agents.  He  would  not  be  guided  by  his  own 
clinical  experience  at  the  bedside,  were  he  to  disregard  the 
result  of  clinical  and  physiological  investigations  which  have 
given  us  concentrated  alkaloids  of  positive  action  to  replace 
crude  drugs,  and  which  have  brought  forth  an  entire  series 
of  new  products  of  the  mineral  world — chiefly  the  coal  tar 
series,  whose  effects  upon  some  of  our  most  important 
physiological  processes  border  on  the  marvelous.  Drugs 
which  possess  the  power  of  reducing  or  increasing  the  rate 
of  the  pulse,  of  diminishing  or  enhancing  its  tension,  of 
lowering  at  will  the  temperature  when  elevated  by  disease, 
of  lulling  to  rest  the  wearied  brain,  of  completely  abolishing 
local  or  general  sensation,  one  or  both,  of  supplying  deficient 
elements  in  gastric  juices,  neutralizing  peccant  matter  in  the 
gastro-intestinal  tract,  etc. — such  drugs  are  entitled  to  the 
respectful  and  careful  attention  of  the  conscientious  physi- 
cian. Of  all  men  the  physician  should  be  broad  and  liberal, 
and  should  shrink  from  all  exclusive  or  universal  remedies. 
For  this  reason  I  beg  to  emphasize  my  belief  in  all  those 
drugs  whose  effects  have  been  positively  demonstrated  in  the 
laboratory  and  at  the  bedside,  while  I  espouse  water  as  per- 
haps the  most  potent  of  all  remedial  measures,  upon  the 
historical,  physiological,  and  clinical  grounds  succinctly  set 
forth  in  the  following  pages.      Herein  lies  the  distinction  be- 


XV. 

tween  hydrotherapy  and  hydropathy;  the  former  accepting 
water  as  one  important  remedial  agent,  the  latter  regarding 
it  as  a  universal  remedy.  The  term  water-cure,  too,  is  un- 
fortunate, inasmuch  as  it  implies  a  specific  certain  effect.  It 
is  translated  from  the  German  Wasser-Kur,  which  in  Ger- 
man really  does  not  convey  the  meaning  of  a  cure,  but 
simply  a  treatment,  as  is  indicated  by  its  Latin  derivation, 
cura^  "  a  care." 

The  subject  will  be  presented  in  an  aspect  different 
from  that  in  which  it  has  been  treated  hitherto.  Recent  ad- 
vances in  therapeutics  have  developed  important  effects  of 
water  which  are  out  of  the  limits  of  the  lines  usually  drawn 
by  authors  on  this  subject. 

It  is  the  aim  of  this  work  to  present  the  subject  en- 
tirely, from  the  standpoint  of  the  clinical  observer,  who, 
standing  at  the  bedside,  weighs  the  claims  of  water  in  the 
balance,  and  selects  from  the  best  scientific  work  and  from 
the  enormous  quantity  of  chaff  in  which  the  teaching  and 
practice  of  empirics  have  buried  the  golden  wheat  such 
truths  as  have  not  only  a  rational  theoretical  basis,  but 
have  been  actually  verified  by  large  clinical  and  hospital 
experience,  larger,  indeed,  than  most  other  therapeutic 
measures  may  boast  of. 


CHAPTER    I. 

HISTORY. 

The  application  of  pure  water  in  or  upon  any  part 
of  the  human  body  for  remedial  purposes  is  known  as 
Hydrotherapy.  This  term,  therefore,  includes  the 
use  of  water  in  any  form,  from  ice  to  vapor,  internally 
or  externally. 

It  is  not  an  infrequent  error  to  regard  the  exter- 
nal application  of  cold  water,  or  its  combination  with 
cold  water  drinking,  as  in  the  so-called  water-cure,  as 
the  only  aim  of  hydrotherapy.  The  modern  applica- 
tion of  the  term,  on  the  contrary,  embraces  every 
method  by  which  pure  and  unadulterated  water  is 
utilized  in  the  treatment  of  disease.  The  surgical 
use  of  hot  water  for  purposes  of  asepsis,  the  gynaeco- 
logical application  for  the  treatment  of  pelvic  inflam- 
mation, Its  internal  use  in  gastric  derangements,  the 
need  of  tepid  temperature  in  intestinal  diseases,  all 
these  belong  to  the  field  of  hydrotherapeutics,  because 
they  depend  upon  the  effect  of  temperature  and 
mechanical  results  of  water  alone. 

The  successful  application  of  ice  (frozen  water) 
in  cardiac  and  inflammatory  affections  furnishes 
another  illustration  of  the  value  of  modern  hydro- 
therapy. The  use  of  vapor  in  rheumatic  and  other 
affections  belongs  to  the  same  category.  The 
author  does  not  propose  to  confine  himself  to  the  ex- 


ternal  and  internal  use  of  cold  water,  as  is  the  prac- 
tice of  hydropaths,  but  to  expand  into  a  broader  and 
more  fruitful  field,  whose  limitations  shall  be  that 
water  in  some  shape  is  the  agent  applied  in  the  treat- 
ment. 

DIVISION    OF    THE    SUBJECT. 

It  is  the  aim  of  this  work  to  present  the  claim  of 
hydrotherapy  to  the  reader's  attention  upon  argu- 
ment derived  from  historical,  physiological,  and  clin- 
ical data;  in  other  words,  to  treat  it  precisely  as  all 
other  remedies  are  presented  in  an  essay  on  Thera- 
peutics. 

HISTORY. 

It  is  a  singular  fact  that,  while  other  profes- 
sions and  trades  regard  the  study  of  the  history  of 
their  subject  as  an  important  element  in  their  educa- 
tion, the  physician  alone  permits  this  profitable  field 
to  remain  uncultivated.  The  history  of  the  world, 
says  Kant,  is  the  forum  of  the  world.  It  alone  pre- 
sents to  us  a  portrayal  of  truth,  and  guards  us  against 
error. 

The  history  of  water  as  a  therapeutic  agent  is 
not  only  one  of  the  most  interesting  chapters,  but  it 
affords  the  clearest  demonstration  of  the  instability  of 
therapeutic  propositions  and  the  manner  in  which 
prevailing  ideas  influence  them.  Although  the  litera- 
ture of  the  subject  is  the  most  extensive  published, 
with  regard  to  any  remedy,  recent  works  on  Thera- 
peutics treat  it  with  a  decidedly  stepmotherly  regard; 


—  3  — 
they  dismiss  it  in  a  few  beggarly  lines,  preferring  to 
devote  their  columns  to  essays  upon  the  action  of 
remedies  which  have  been  chiefly  tested  on  animals, 
and  whose  actual  clinical  value  is,  in  most  instances 
at  least,  problematical.  The  history  of  water  teaches 
clearly  that  no  one  remedy  has  so  creditably  passed 
through  vicissitudes  of  depression,  and  that,  despite 
professional  and  lay  prejudice,  it  stands  to-day  un- 
scathed and  rendered  secure  against  assault  by  the 
panoply  obtained  from  physiology  and  bedside  re- 
sults. The  works  of  Hippocrates,  the  father  of  sys- 
tematic medicine,  illustrate  how  a  master-mind  may 
grasp  facts  and  make  deductions  which  may  stand 
the  test  of  time.  Appearing  upon  the  stage  of  action 
at  a  time  when  the  greatest  confusion  had  been 
brought  into  the  treatment  of  disease  by  priests, 
philosophers,  and  physicians,  this  great  genius 
brought  order  out  of  chaos  into  every  branch  of 
medicine,  and  endeavored  to  endow  with  true  scien- 
tific dignity  the  empirical  knowledge  of  the  day.  In 
his  tract  on  the  use  of  fluids  he  laid  down  rules  for 
the  treatment  of  acute  and  chronic  diseases  by  water, 
which  are  to-day  followed  by  empirics  as  well  as  phy- 
sicians, and  which,  together  with  subsequent  devel- 
opments, place  hydrotherapy  among  orthodox  and 
scientific  methods  of  treatment. 

Among  the  Greek  physicians  and  philosophers 
who,  during  the  rise  of  Roman  greatness,  emigrated 
from  their  native  land  to  seek  fame  and  fortune  amid 


the  world-conquering  people  was  Asclepiades,  of 
Prusa.  Leaving  Alexandria  and  Athens  one  hun- 
dred years  B.  C,  he  entered  Rome  under  Marius  and 
Sulla.  Though  belonging  to  a  despised  class,  he 
became  the  bosom  friend  of  Cicero,  and  won  for  him- 
self eminence,  respect,  and  professional  reputation 
because  of  his  great  medical  talents,  his  marvelous 
cures,  and  especially  on  account  of  his  genial  and 
sympathetic  nature.  It  was  his  chief  aim  to  cure  cito^ 
tuto^  et  jucunde.  Hence  he  cast  aside  all  active  medi- 
cation. Although  he  practiced  bleeding,  he  did  so 
cautiously,  and  he  depended  chiefly  on  diet,  rubbing, 
exercise,  and  baths. 

It  will  be  remarked  in  the  history  of  this  subject 
that  the  same  men  whose  judicial  medical  thought 
elevated  them  so  far  beyond  their  contemporaries  as 
to  resist  the  prevalent  practice  of  excessive  venesec- 
tion and  active  medication,  exhibiting  a  regard  for 
the  conservative  tendencies  of  nature  — the  men  who, 
in  those  dark  days  of  medical  history,  approached 
most  nearly  the  spirit  which  governs  the  therapeusis 
of  the  present  enlightened  era — these  were  the  men 
who  were  invariably  pronounced  advocates  of  water  as 
a  remedy.  Asclepiades,  the  philosophical  founder  of 
the  school  from  which  sprang  Themison,  Antonius 
Musa,  Cornelius  Celsus,  Coelius  Aurelianus,  was  so 
warm  an  advocate  of  baths  and  douches  that  he  was 
dubbed  "  Psychrolutus."  Through  him  hydrotherapy 
was  popularized  in  Rome. 


—  5  — 

A  member  of  his  school  it  was,  Antonius  Musa, 
who  maintained  the  aim  of  his  noble  master  to  rescue 
his  calling  from  the  disrespect  with  which  it  was  re- 
garded. To  him  the  Emperor  Augustus  owed  restor- 
ation to  health,  by  a  vigorous  cold-water  treatment. 
Suetonius  tells  us  that  the  grateful  Caesar  bestowed, 
not  alone  upon  Musa  but  upon  the  whole  medical 
profession,  the  privileges  of  citizenship,  besides 
■erecting  to  him  a  statue  next  to  yEsculapius. 

Horace,  too,  was  his  patient.  His  first  book, 
Epistle  vi  (Smart's  Translation),  tells  us:  "Antonius 
Musa  pronounces  Baieae  to  be  of  no  use  to  me,  yet 
makes  me  obnoxious  to  the  place,  when  I  am  bathed 
in  cold  water  even  in  the  midst  of  frost,  by  his  pre- 
scription." 

Cornelius  Celsus,  the  learned  Roman  (called 
Latinorum  Hippocrates,  Medicorum  Cicero),  the 
bosom  friend  of  Ovid  and  companion  of  Fabius  Max- 
imus,  prescribed  water  freely  in  acute  and  chronic 
diseases.  His  opinions  on  the  prevalent  blood-letting 
mania  mark  him  as  an  eclectic  of  the  highest  type. 
The  same  may  be  said  of  Coelius  Aurelianus,  who 
was  the  originator  of  the  abdominal  compress  of  wet 
sponge  for  hypochondriacs.  Galen,  too,  was  an  able 
and  judicious  advocate  of  cold-water  baths,  and 
advised  cold  affusions  upon  the  head,  while  the  body 
was  immersed  in  warm  water. 

In  the  dark  days  of  medicine  which  followed  the 
death  of  Galen,  when  all  branches  of  human  knowl- 


—  6  — 

edge  suffered  from  the  ignorance,  witchcraft,  and 
fraud  arising  from  the  barbarism  of  migratory  peoples, 
from  the  destruction  of  the  Alexandrian  library  and 
school,  from  the  demolition  of  the  Roman  Empire, 
the  plundering  of  Saracens,  and  the  conquest  of 
Spain,  science  and  art  lay  prostrate.  At  this  time 
appeared  Alexander  of  Tralles  and  Paulus  .-Egineta. 
The  former  refused  to  rely  upon  any  system  of  medi- 
cine, but  insisted,  with  a  true  philosophical  spirit 
which  would  do  credit  to  him  to-day,  that  the  physi- 
cian must  depend  in  each  single  case  upon  the  age, 
constitution,  natural  powers,  and  mode  of  life  of  the 
patient,  as  well  as  upon  the  climate  andallied  condi- 
tions and  effects  of  nature.  He  furnished  directions- 
for  bathing  and  rubbing  in  many  diseases. 

Paulus  x^gineta,  who  is  regarded  as  the  greatest 
physician  of  the  seventh  and  eighth  centuries,  was  an 
enthusiastic  advocate  of  water,  and  he  it  was  who  first 
advised  the  cold  douche  for  sunstroke  and  anuria. 
The  next  prominent  figure  in  the  history  of  hydro- 
therapy is  Savanarola,  the  grandfather  of  the  unhap- 
pily famous  professor  of  Ferrara.  He  recommended 
baths  in  fevers,  dysentery,  leucorrhoea,  and  debility. 
No  history  seems  to  be  complete  without  the  Chinese. 
Julien  (Comptes  Rendus,  1849)  ^^^^^  ^s  that  in  the 
annals  of  the  dynasty  of  Ha,  the  biography  of  Hoa,  a 
celebrated  physician,  is  written.  Hoa  used  hydro- 
therapy by  sweating  and  cold  water.  The  historian 
relates  that  in  a  case  of  rheumatism  Hoa  ordered  one 


—  7  — 
hundred  affusions.  After  the  seventeenth  the  woman 
thought  herself  dying;  after  the  twenty-fourth  re- 
action ensued,  "  the  internal  heat  came  through  all 
her  pores,  rising  in  vapor  two  feet  above  her  head. 
After  the  one  hundredth  she  was  put  into  a  warm 
bed." 

In  the  seventeenth  century  Herman  van  der 
Heyden  regarded  water  as  a  panacea,  reporting  three 
hundred  and  sixty  cases  of  malignant  dysentery  cured 
by  its  use.  Van  Helmont  and  his  son  advocated 
ablutions  and  affusions. 

Passing  over  lesser  events,  we  come  to  an  epoch 
in  hydrotherapy  created  by  Floyer,  an  educated  Eng- 
lish physician,  whose  book,  published  in  1697,  passed 
through  six  editions  and  was  translated  into  German 
forty  years  later.  He  energetically  propagated  his 
views  by  his  writings,  making  many  converts  at  home 
and  abroad. 

Those  who  are  familiar  with  the  names  of  great 
English  physicians  will  appreciate  the  value  of  such 
names  as  Pitcairne  Blair,  Cheyne,  Huxham,  who  were 
advocates  of  water  in  disease.  Floyer  was  succeeded 
in  the  advocacy  of  hydrotherapy  by  Fridrich  Hoff- 
man, the  most  illustrious  physician  of  Europe  at  that 
time.  He  held  a  professorial  chair,  and,  commanding 
great  respect,  found  many  followers.  The  first  dis- 
tinct recognition  of  the  influence  of  water  upon  the 
tone  of  the  tissue  came  from  this  philosophical  clini- 
cal teacher.     His  doctrines  were  imported  into  Italy, 


—  8  — 

and  thence  found  their  way  to  France  and  back  again 
to  England,  where  Floyer  had  prepared  the  way. 
Theden,  the  surgeon  of  Frederick  the  Great,  was  the 
first  to  use  water  in  smallpox,  malignant  fever,  rheu- 
matism, and  inflammation  of  the  joints.  He  improved 
the  shower  bath,  and  warmly  advised  its  use.  In 
1743  a  Silesian  physician,  Johann  Sigmund  Hahn, 
and  his  son  established  the  principles  of  modern 
hydrotherapy  in  Germany,  applying  it  in  acute  and 
chronic  diseases,  especially  in  smallpox  and  the  other 
exanthemata. 

Hence  the  same  country  which  later  produced 
the  first  great  empiric,  Priessnitz,  may  be  credited 
also  with  the  first  great  hydrotherapeutist. 

During  the  prevalence  of  the  pest  in  Moscow  in 
1 88 1,  cold  water  was  used  very  successfully. 

English-speaking  physicians  are  perhaps  better 
acquainted  with  the  works  of  Wright  and  Currie  in 
the  treatment  of  acute  fever  than  with  any  other  his- 
torical fact  in  hydrotherapy.  Currie's  work  was 
translated  into  several  foreign  languages,  and  his 
practice  was  introduced  into  the  Vienna  hospitals  by 
Joseph  Franck.  His  application  of  water  was  not 
limited  to  fevers.  In  gout  and  convulsions,  paralysis, 
tetanus,  and  other  diseases  he  claims  to  have  obtained 
good  results.  To  mention  Hufeland,  the  enthusias- 
tic and  yet  judicious  advocate  of  hydrotherapy,  is  to 
give  the  imprint  of  true  medical  wisdom  to  it,  and  to 
indicate  its  wide  adoption  among  the  profession.     He 


•offered  a  prize  for  the  best  treatise  on  the  action  of 
cold  water  in  fevers,  determined  by  scientific  thermo- 
metrical  study.  Dr.  Froelich,  a  Vienna  professor, 
was  the  most  successful  of  three  competitors,  all  of 
whose  essays  were  published  in  1823  by  Hufeland. 

But,  despite  these  eminent  and  enthusiastic  advo- 
cates, hydrotherapy  did  not  become  popular  until  the 
appearance  of  the  peasant  Priessnitz.  His  history  is 
so  familiar  that  he  is  erroneously  regarded  by  many 
as  the  father  of  the  water  treatment.  In  1840  he  had 
treated  over  1,500  patients  from  all  parts  of  the 
world  by  the  methods  he  had  invented;  and  when  he 
died,  twelve  years  later,  he  had  amassed  several  mil- 
lion's. The  impression  made  by  this  empiric  marks 
an  epoch  in  hydrotherapy.  His  success  was  brilliant 
because  he  was  a  careful  observer,  a  good  judge  of 
human  nature,  and  his  mechanical  skill  enabled  him 
to  invent  various  technical  modifications  of  the  water 
treatment,  many  of  which  have  been  adopted  by  the 
profession  and  are  still  in  use.  A  copious  literature 
sprang  up  in  all  parts  of  the  world,  and  many  institu- 
tions were  modeled  after  his.  The  Government  built 
roads  to  facilitate  access  to  his  establishment;  monu- 
ments and  fountains  were  erected  to  his  memory. 
Physicians  from  all  countries,  who  had  been  attracted 
to  the  Silesian  peasant's  mountain  home,  became  con- 
verts to  and  missionaries  of  his  practice. 

An  interesting  chapter  in  the  history  of  hydro- 
therapy is  furnished  by  an  incident  in  1839.     Doctors 


Engel  and  Wertheim  petitioned  the  French  Govern- 
ment for  permission  to  open  a  hydropathic  institution. 
The  petition  was  referred  to  the  French  Academy  of 
Medicine,  which  appointed  a  committee  consisting  of 
Bouilland,  Velpeau,  and  Roche.  The  last  named  de- 
livered such  a  tirade  against  hydrotherapy,  character- 
izing it  as  dangerous,  unscientific,  chimerical,  and  op- 
posed to  the  simplest  laws  of  physiology  and  pathology,, 
that  the  sixty  members  present  made  an  adverse  report 
amid  great  applause.  Ou  this  report  the  Minister  of 
Instruction  refused  to  grant  permission  for  the  erec- 
tion of  hydropathic  establishments  to  Engel  and 
Wertheim.  These  physicians  appealed  from  the  de- 
cision of  the  Academy,  and  requested  the  authorities 
to  investigate  hydrotherapy  in  the  hospitals.  This 
was  done  .  in  the  Hospital  Saint  Louis,  under  MM. 
Gibert  and  Devergie,  in  1841.  These  made  a 
favorable  report,  resulting  in  the  withdrawal  of  the 
interdiction  previously  ordered.  Thus  has  it  ever 
been  when  the  biased  views  of  inexperienced  oppo- 
nents were  met  by  clinical  demonstrations  in  hydro- 
therapy. Bouilland,  the  chairman  of  the  committee, 
recanted  after  obtaining  such  practical  evidence. 

A  few  years  later,  Scoutetten  was  sent  to  Ger- 
many by  Marshal  Soult  to  study  hydropathy.  He  re- 
ported that,  while  it  cannot  be  reckoned  a  universal 
method,  it  exercises  an  undoubted  influence  on  the 
public  health,  and  the  numerous  permanent  cures  it 
has  wrought  in   intelligent   persons  recommend  it  to 


popular  attention,  etc.  "  It  lies  in  the  interest  of 
humanity  and  medical  science  that  demonstration  of 
the  forms  and  aids  of  hydropathy  in  Paris  should 
take  place  under  the  eyes  of  able  physicians."  This 
report  gave  a  great  impetus  to  the  development  of 
hydrotherapy  among  French  physicians,  to  whose 
honor  it  redounds  to-day  in  the  works  of  Lubanski, 
La  Tour,  Schedel,  Fleury,  Duval,  Dujardin-Beaumetz^ 
Charcot,  Valleix,  Delmas,  Keller  and  others. 

The  great  Magendie  aided  its  propagation  by 
physiological  demonstrations.  But  Fleury  founded 
almost  a  separate  school  of  hydrotherapy  by  the  in- 
troduction of  douches  as  the  chief  method,  fortifying 
his  clinical  results  by  physiological  and  rational  de- 
ductions. 

Modern  fever  treatment  received  its  great  initia- 
tive from  Ernest  Brand,  who  in  1861  published  his 
remarkable  results  from  immersion  and  compresses  of 
water  from  54°  to  68°  F.  Bartels  and  Juergensen  are 
names  familiar  to  the  present  generation.  Vienna 
became  a  great  centre  of  hydrotherapy,  which  it  has 
remained  under  Winternitz,  its  chief  modern  pro- 
moter, the  corypheus  of  scientific  hydrotherapy. 

This  rapid  and  imperfect  review  brings  us  down 
to  the  present  day,  when  great  clinical  teachers  re- 
affirm their  faith  in  a  method  of  treatment  which  had 
received  the  highest  encomiums  from  Hippocrates,, 
Asclepiades,  Celsus,  Hufeland,  and  Currie. 

Niemeyer,  in  his  book  on  practice,  says  of  it  in 


•scrofula:  *'A  series  of  cases  are  on  record  in  which 
complete  and  perfect  cures  have  been  obtained  by 
these  means,  after  all  other  methods  of  treatment 
have  been  applied  in  vain." 

Dujardin-Beaumetz  said  in  his  lectures  at 
I'Hopital  Cochin  in  1887:  "The  benefits  we  obtain 
from  cold  water  in  the  cure  of  disease  arise  from  its 
physiological  effect  upon  the  circulation,  the  nervous 
•system,  the  nutrition,  and  from  its  revulsive  and  heat- 
lowering  influence." 

Prof.  M.  Peter,  of  the  Paris  School  of  Medicine, 
in  his  preface  to  the  magnificent  clinical  work  on 
hydrotherapy  of  Duval,  published  by  Bailliere,  says: 
"  Hydrotherapy  sufflces  in  most  cases  of  disease; 
added  to  other  treatment,  it  is  a  most  powerful 
auxiliary.  Can  any  one  speak  better  or  say  more  of 
it  ?"  he  asks. 

"*  In  his  classical  contribution  to  V.  Ziemssen's 
cyclopaedia,  Prof.  Erb  offers  this  testimony:  "  To 
the  most  important  and  most  active  agents  in  the 
therapeutics  of  our  field  (nervous  diseases)  belong 
cool  and  cold  baths,  viz.,  the  application  of  cold  water 
in  the  most  varied  forms;  that  which  is  usually 
termed  '  cold  water  treatment.'  Having  been  in  re- 
cent times  practiced  more  rationally  and  studied 
more  exactly,  it  has  attained  remarkable  prominence. 
Its  results  in  all  possible  forms  of  chronic  nervous  diseases 
are  extraordinarily  favorable.  If  we  add  to  this  the 
heightened    skin    and    muscular    action    induced    by 


—  13  — 

various  methods  of  bathing,  the  influence  of  diet,  etc., 
it  becomes  evident  that  we  possess  few  remedies  which 
produce  an  equally  poiverful  effect  upon  the  nervous  sys- 
tem."     The  italics  are  mine. 

Semmola,  Professor  of  Therapeutics  in  the  Naples 
University,  whose  lectures  (1890)  have  been  trans- 
lated into  German  and  have  received  a  laudatory  pre- 
face from  Prof.  Nothnagel,  says:  "Hydrotherapy 
stimulates  cutaneous  activity,  and  with  it  all  functions 
of  tissue  change  and  organic  purification,  so  that 
often  real  marvels  of  restoration  in  severe  and  des- 
perate cases  are  accomplished.  Unfortunately,  these 
remarkable  results  are  more  rare  to-day  than  they 
were  in  the  time  of  Priessnitz,  of  which  I  was  myself 
a  witness.  The  reason  appears  to  lie  in  the  fact  that 
hydrotherapy  has  become  the  monopoly  of  the  exclu- 
sively trade  doctors,  who  treat  the  various  maladies 
without  strict  selection  of  the  hydriatic  procedure  in 
each  case,  etc.  Without  going  here  into  the  mechan- 
ism by  which  a  rational  and  earnestly  practiced 
hydrotherapy  may  lead  to  a  rapid  and  truly  organic 
renovation,  provided  that  the  apparatus  of  the  econ- 
omy is  capable  of  responding  to  the  increased  labor 
thrown  upon  it,  one  thing  is  certain,  that  restoration 
of  the  organs  can  only  be  attained  by  physiological 
agencies,  /.  e.,  by  measures  which  act  in  accord  with 
normal  functions. 

"//  is  to  be  regretted  that  physicians  in  general  do 
fiot  place  the  estiinate  iipon  hydriatic  treatment  which  it 


—   14  — 

deserves,  for,  with  the  exception  of  diseases  of  the 
nervous  system  (in  which  the  water  treatment  is  often 
used  in  a  most  senseless  manner),  little  and  bad  use 
is  made  of  it  in  diathetic  affections. 

"  Those  who  were  in  the  position  to  follow  up  the 
€ures  of  Priessnitz  will  remember  well  what  remark- 
able and  unexpected  curative  successes  were  obtained 
at  Grafenberg  by  means  of  the  cold  water  treatment. 

"  Let  me  impress  upon  you  firmly  this  classical 
method  of  evoking  and  furthering  a  rational  therapy, 
which  powerfully  contributes  to  rejuvenate  the  powers 
of  the  organism,  and  thus  best  secures  therapeutic 
success.  There  are  other  diseases  of  tissue  change, 
in  which  hydrotherapy  offers  a  rational  aetiological 
therapy.  I  refer  to  those  alterations  in  tissue  change 
which  are  exclusively  the  result  of  vicious  modes  of 
life.  In  all  these  cases,  which  may  be  united  under 
the  common  term  of  retardation  of  tissue-metamor- 
phosis, hydrotherapy  presents  a  truly  rational  treatment, 
and  therefore  certain  and  imf ailing  effects,  unless  the 
local  processes  have  reached  incurable  limits  (ather- 
oma, visceral  arterio-sclerosis,  etc.).  In  these  cases, 
indeed,  pharmacology  alone  is  also  powerless  in  its 
results." 

Prof.  F.  A.  Hoffman,  of  Leipsic  University,  in 
his  lectures  on  General  Therapeutics  (F.  C.  Vogel, 
1888),  which  were  regarded  by  the  reviewer.  Prof. 
Ewald,  as  the  most  able  exposition  of  the  subject  in 
recent   times,  says  (p.  82):  ''Herein   lies  the  unsur- 


—  15  — 
passed  value  of  cold  water  in  therapeutics;  we  invig- 
orate the  nervous  system,  and  through  it  the  capacity 
for  work  may  be  enhanced  in  the  heart  itself.  Ex- 
perience at  the  bedside  occasionally  presents  to  us 
really  surprising  things.  .  .  .  What  we  have 
learned  in  the  most  varied  cerebral  and  spinal  dis- 
eases, we  may  apply  also  to  other  organs.  Cold  water 
is  a  therapeutic  agent  by  whose  correct  application 
we  may  most  surely  and  without  danger  of  reaction 
exercise  and  invigorate  the  nervous  system,  and  here- 
in I  seek  its  fundamental  significance  in  the  treatment 
of  all  possible  internal  diseases." 

On  page  41  he  says  of  baths:  "  We  shall  have 
much  to  say  of  them,  and  see  that  they  are  much 
more  important  by  reason  of  their  effect  upon  the 
nutrition  and  activity  of  the  inner  organs,  so  that 
their  direct  effect  upon  the  skin  falls  into  the  back- 
ground." 

On  page  385  he  sums  up  as  follows:  "  If  we  re- 
view briefly  the  bath  treatment,  we  find  very  great 
uniformity  in  its  effects;  almost  everywhere  do  we  see 
the  treatment  of  gout,  rheumatism,  scrofula,  chronic 
infarctions  and  exudations  brought  forward  as  indi- 
cations. 

"  If  we  add  old  cases  of  syphilis,  we  have  enumer- 
ated nearly  all  diseases  which  are  treated  by  baths. 
Effects  upon  the  heart,  lungs,  liver,  stomach,  intes- 
tines, and  kidneys  are  rarely  thought  of.  /  believe  that 
a  great  gap  exists  here. 


—  i6  — 

"We  have  spoken  everywhere  of  the  significance 
of  baths  for  the  improvement  of  all  organs,  but  we 
also  have  become  convinced  of  the  great  difficulty  of 
correctly  estimating  their  effect  with  precision. 
Nevertheless  /  a7n  convinced  that  in  time  all  chronic 
diseases  of  the  organs  will  be  drawn  into  the  dornain  of 
the  bath  treatment^     The  italics  are  mine. 

The  following  testimony  from  one  of  the  most 
justly  eminent  general  practitioners  in  America  is 
interesting  in  this  connection.  The  University  Medi- 
cal Magazine  (Nov.,  1891)  contains  the  following 
letter: 

Professor  H.  C.  Wood: 

Dear  Doctor :  Your  paper  on  the  Local  Treatment  of 
Dysentery  should  surely  impel  others  to  give  it  a  trial. 
What  you  accomplished  by  the  introduction  of  pieces  of  ice 
might,  however,  be  obtained  more  pleasantly  to  the 
patient  by  the  application  of  ice-water  cloths  over 
the  belly,  especially  over  the  course  of  the  lower 
colon,  with  half  a  pint  or  pint  injections  of  cold  water  into 
the  rectum.  //  is  amazing  to  me  that  so  few  physicians  use  cold 
as  a  re7nedy  in  inflammatory  affections.  Of  all  means  of  cure  in 
such  affections,  %vherever  studied  so  that  the  remedy  can  be  applied, 
there  is  not  one  to  equal  it.  In  pleurisy,  pneumonia,  peritonitis, 
and  all  other  "  itis  "  it  is  a  most  efficient  remedy.  Moder- 
ately applied  in  measles,  smallpox,  and  scarlet  fever,  no 
remedy  equals  it.  Think  of  the  one  fact  that  in  sixty  years, 
with  thousands  of  children  with  measles,  I  never  lost  one 
from  that  disease.  In  scarlet  fever  I  never  had  a  remedy 
to  equal  the  application  of  cold.  I  scarcely  ever  did  anything 
in  measles,  save  gave  a  laxative,  and   then  kept  the  patient 


—  17  — 

cool — often  sponged  the  whole  body  with  cool  water,  and 
always  gave  cold  drink  in  abundance — gave  it  copiously  as  a 
cooling  remedy.  I  am  not  boasting — only  forcing  on  your 
attention  facts — regular  "  Gradgrind "  facts.  And  I  do  it 
because  I  know  that  if  you  can  be  convinced  of  the  value  of 
the  remedy,  you  have  the  manliness  and  the  courage  to  advo- 
cate it.     Farewell. 

As  ever,  your  friend, 

Hiram  Corson. 
Maple  Hill,  Au^st  i6th,  1891. 

I  might  multiply  these  opinions  ad  mfitiitum. 
But  I  have  selected  them  from  men  who  are  not 
special  hydrotherapeutists,  but  who  are  teachers  of 
medicine  in  the  best  schools  of  Germany,  Italy,  and 
France — men,  too,  who  are  known  everywhere  as  re- 
presentatives of  good  clinical  teaching. 

History  has  repeated  itself  here  as  in  other  de- 
partments. The  opinions  of  the  most  judicious, 
philosophical,  and  successful  physicians  of  past  ages 
have  been  sustained  by  the  judgment  of  the  most  en- 
lightened era.  The  student  of  the  history  of  hydro- 
therapy must  observe  that  it  has  passed  through 
many  cycles  in  the  estimation  of  physicians.  The 
causes  of  these  fluctuations  must  be  brought  out,  in 
order  to  avoid  their  adverse  influence  in  the  future. 

With  the  dawn  of  systematic  medicine  came  the 
promise  of  a  rational  appreciation  of  water  as  a  rem- 
edy, which,  however,  was  overshadowed  by  the  ten- 
dency of  its  followers  to  build  pseudo-philosophic 
systems  rather  than  to  enlarge  the  practical  domain  of 


—    iS  — 

therapeutics.  Just  as  among  the  ancients  we  find 
the  most  renowned  physicians  the  most  active  advo- 
cates of  water  as  a  remedy,  so  does  its  history  in  mod- 
ern times  develop  the  same  fact.  The  simphcity  of 
this  remedy,  however,  antagonized  the  pedantic  and 
self-important  members  of  the  profession;  and  when 
laymen,  who  must  have  learned  its  value  from  observ- 
ing its  effects  in  the  hands  of  physicians,  espoused  it, 
the  latter  became  entirely  estranged.  Thus  did  it 
come  about  that  Priessnitz  created  a  sect,  the  Hydro- 
paths,  whose  influence  for  the  popularization  of  the 
treatment  was  in  inverse  ratio  to  its  adoption  by  the 
profession.  And  this  blighting  effect  of  the  empirical 
espousal  of  water  as  a  remedy  is  to-day  mainly  re- 
sponsible for  the  aversion  which  physicians  feel  to  its 
adoption.  Are  we  just  to  ourselves  or  to  those  who 
entrust  their  lives  and  health  into  our  keeping  in 
maintaining  this  attitude  ?  Due  reflection  must  bring 
us  to  realize  the  fact  that  the  application  of  water  in 
disease  is  the  most  orthodox  therapeutic  measure  in 
medicine,  having  (as  I  have  shown)  been  fully  treated 
by  Hippocrates,  and  taught  by  those  most  eminent 
and  judicious  men  who  have  made  medical  history. 
Even  many  of  those  methods  which  are  usually 
regarded  as  inventions  of  Priessnitz  owe  their  origin 
to  physicians  who  lived  long  before  his  time.  The 
abdominal  wet  compress,  for  instance,  was  originated 
by    Coelius   Aurelianus.*     And    nearly  one    hundred 

*  Lucas;  An  Essay  on  Water.     London,  1756. 


—  19  — 

years  before  this  Silesian  peasant  became  famous,  the 
Doctors  Hahn,  who  were  also  Silesians,  applied  water 
in  acute  and  chronic  diseases,  including  smallpox, 
scarlatina,  and  measles. 

The  broad  Catholicism  which  characterizes  mod- 
ern medicine  had  liberated  hydrotherapy  from  the 
absurd  stigma  of  its  empirical  relationship.  The  vio- 
lent methods  of  treatment  prevalent  in  the  first  five 
decennia  of  this  century  were  gradually  usurped  by 
more  rational  methods.  When,  in  fact,  a  therapeutic 
nihilism  threatened  to  take  their  place,  water  again 
came  to  the  fore  as  the  one  substantial  and  promising 
remedial  agent,  in  acute  diseases  at  least.  Again, 
Brand,  Juergensen,  Ziemssen,  and  their  followers, 
brought  the  value  of  hydrotherapy  to  the  attention  of 
the  profession  by  undoubted  tests  at  the  bedside. 
The  battle  was  almost  won;  from  all  countries  the 
echo  of  victory  was  resounding,  but  the  erroneous 
idea  that  the  sole  object  of  the  bath  was  the  reduc- 
tion of  temperature  proved  the  rock  upon  which  this 
invaluable  antipyretic  was  again  to  split,  as  it  had 
done  after  the  days  of  Hippocrates,  of  Hahn,  Hufe- 
land,  and  Currie.  Antipyresis  became  the  misleading 
watchword  of  fever  treatment.  Before  the  invention 
of  chemical  antipyretics,  water  was  the  only  reliable 
agent  for  reducing  temperature,  against  which  quinine 
struggled  in  vain  for  rivalry.  Now  the  busy  chemist 
came  to  the  fore  and  astonished  the  medical  world 
by  the  discovery  of  true   antithermic  agents,  whose 


20    

influence  upon  temperature  reduction  was  undoubted* 
and  marvelous  in  its  precision.  It  was  not  long, 
however,  ere  the  cHnical  tests  discovered  the  inad- 
equacy, indeed  the  perniciousness,  of  relying  upon 
mere  temperature  reduction  for  therapeutic  success. 
"  I  am  an  enemy  to  all  antipyresis,"  said  an  eminent 
Berlin  professor  to  me  last  year.  "  Although  I  was 
educated  in  the  school  of  Traube,  who  was  a  warm 
advocate  of  bathing,  I  regard  antipyresis  as  a  false 
therapy.  Away,  therefore,  with  the  bath,  because  it 
is  an  antipyretic."  Thus  has  it  come  about  that 
hydrotherapy  in  acute  disease  is  abandoned  by 
many,  while  in  chronic  disease  it  increases  its  hold  on 
the  profession  in  certain  parts  of  the  world. 

To-day  the  best  clinical  teachers  are  making  an 
effort  to  prevent  water  from  sharing  the  fate  of 
chemical  antipyretics.  This  subject  will  be  more 
fully  referred  to  in  the  chapters  on  Fever  Treatment. 
I  must  call  attention,  however,  to  a  new  danger  which 
threatens  hydrotherapy.  The  excessive  medication, 
combined  with  blood-letting,  which  characterized 
medicine  in  the  early  part  of  this  century  and  in  the 
previous  history,  gave  way  to  what  was  termed  thera- 
peutic conservatism.  The  writings  of  Bigelow  and 
Flint  in  this  country,  and  of  Wunderlich  and  others  in 
Europe,  developed  the  expectant  method  of  treat- 
ment, which  aided  the  system  in  its  battle  against 
disease  instead  of  fighting  the  latter  at  the  expense  of 
the  former.     A   therapeutic   nihilism   resulting    from 


21    

"the  abandonment  of  excessive  medication  ensued, 
which  endured  until  very  recently,  when  certain  medi- 
cinal agents,  as  salicylic  acid,  antipyrin,  etc.,  were 
proved  to  produce  definite  therapeutic  effects. 

To-day  the  student  is  no  longer  tortured  by  the 
necessity  of  mastering  needless  materia  medica,  es- 
pecially botanical  details.  But  the  other  extreme  has 
ensued;  many  physicians,  especially  in  Germany,  shrug 
their  shoulders  when  discussing  treatment,  while  they 
glow  with  enthusiasm  when  the  bacteriological  or 
pathological  aspect  of  the  case  is  considered. 

The  quack  and  semi-quack  who  haunt  the  flanks 
of  the  medical  army,  as  the  guerilla  does  that  of  a 
nation,  have  picked  up  some  of  these  nihilistic  (con- 
servative ?)  ideas.  The  result  is  the  formation  of  a 
sect  of  natural physiciaiis  (Naturarzte),  who  propagate 
their  therapeutic  ideas  by  lectures,  books,  and  periodi- 
cals, and  thus  succeed  in  driving  the  physician  from 
the  field.  Men  like  Father  Kneippe  use  cold  water 
as  the  chief  remedy,  while  others  more  or  less  intelli- 
gent— teachers,  preachers,  and  men  and  women  of 
all  conditions — have  constructed  upon  hot  and  cold, 
vapor,  and  hot-air  baths,  exercise,  massage,  and  diet, 
.a  system  of  Natur-heilkunde,  which  must  very  soon 
bring  reproach  upon  hydrotherapy.  The  latter  is 
their  chief  reliance;  these  men,  being  uneducated, 
-apply  it  empirically,  and  propagate  their  errors  among 
the  people.  There  is  a  large  institute  at  Chemnitz, 
in  Saxony,  devoted  to  the  treatment  of  natural  rem- 


edies,  which  I  have  visited,  and  there  are  many  smaller 
ones  in  other  parts  of  Germany. 

It  is  a  singular  paradox  that  the  German  Govern- 
ment does  not  protect  the  people  against  these  un- 
educated quacks.  Whether  they  shall  be  allowed  to 
pursue  their  calling  here  remains  to  be  decided. 
Thus  far  I  know  only  one  such  hydrotherapeutic  in- 
stitute in  New  York,  in  which  the  treatment  is  most 
crude  and  unscientific,  and  under  the  management  of 
an  ordinary  masseur.  Let  not  the  profession  stand 
idly  by  and  allow  again  the  value  of  water  as  a  rem- 
edial means  to  be  overshadowed  by  the  efforts  of 
these  unskilled  advocates.  If  they  can  obtain  good 
therapeutic  results,  which  I  do  not  doubt,  how  much 
more  may  a  correct  and  rational  application  of  the 
remedy  accomplish. 


CHAPTER  II. 

MODE  OF  ACTION   OF  WATER. 

In  the  consideration  of  therapeutic  measures  it  is 
important  to  define  their  mode  of  action  as  far  as 
has  been  ascertained  by  trustworthy  observation.  So 
long  as  the  art  of  medicine  represented  only  the 
aggregate  of  a  large  mass  of  empirical  observations, 
our  predecessors  were  content  with  following  the 
dicta  of  those  to  whose  teaching  they  listened  or 
whose  writings  they  consulted.  The  dawn  of  the 
inductive  method  engrafted  a  more  rational  basis 
upon  medical  practice.  As  a  result,  remedies  are 
now  subjected  to  tests  other  than  merely  clinical, 
either  before  or  after  they  have  come  into  practical  use. 

Fortunately,  we  are  able  to  distinctly  trace  the 
remedial  effects  of  water  upon  physiological  paths, 
and  to  make  from  these  our  therapeutic  deductions. 

It  is  proposed  to  show  here^  how  water  may  in- 
fluence the  most  important  functions  of  the  human 
body  in  health  ere  the  reader  will  be  asked  to  accept 
its  applications  in  disease. 

The  effect  of  water  upon  the  human  body  is 
complex  in  accordance  with  the  method  of  its  appli- 
cations. 

INTERNAL    USE  OF    WATER. 

The  internal  use  of  water  is  distinct  in  effect  from 
the  external  use,  as  is  the  case  with  any  other  thera- 
peutic agent. 


—  24  — 

The  importance  of  water  as  a  constituent  of  all 
secretions  and  excretions,  as  well  as  of  all  tissues,  is 
so  trite  a  physiological  fact  that  it  is  referred  to  here 
only  in  order  to  emphasize  the  effect  of  changes 
which  may  be  produced  in  these  by  its  increased 
imbibition. 

That  water  received  into  the  stomach  or  rectum 
acts  upon  the  temperature  of  the  body  has  been  estab- 
lished by  numerous  observers.  But  not  only  is  a 
direct  reduction  of  temperature  produced  by  the 
imbibition  of  cold  water.  We  have  here  also  a  milder 
effect  by  reflex  channels  which,  as  will  be  shown 
later,  are  observed  when  water  is  applied  externally, 
as  is  most  frequently  done  in  practical  hydrotherapy. 

The  reflex  effect  upon  the  vaso-motor  nerves, 
the  consequent  contractions  of  peripheral  vessels,  and 
changes  in  their  tension  were  clearly  pointed  out  by 
Winternitz.  As  long  ago  as  1864  he  demonstrated 
the  effect  of  cold  water  drinking  upon  the  pulse,  by 
the  following  sphygmographic  tracings: 


Before  drinking  ^A,  quart  water  at  43°  F. 


After  drinking  the  same. 


—  25  — 

These  tracings  clearly  show  that  immediately 
•after  drinking  very  cold  water  the  ascension  lines 
are  shortened  and  become  less  perpendicular,  indi- 
cating an  increased  tension  in  the  radial  artery. 

In  order  to  prove  that  the  effect  is  entirely  due 
to  the  temperature  of  the  imbibed  water,  the  above 
tracings  may  be  compared  to  the  following,  taken  be- 
fore and  after  drinking  0.3  litres  of  water  of  about 
90°  F. 


Before  drinking  >^  quart  water  at  90°  F. 


.After  drinking  the  same. 

The  change  in  the  ascension  lines  is  precisely 
reversed.  That  this  effect  is  not  due  to  the  simple 
increase  of  fluid  by  absorption  or  by  direct  cooling  or 
warming  of  the  blood  is  demonstrated  by  the  fact 
that  it  is  observed  too  quickly  after  imbibition.  It 
must  be  the  result,  therefore,  of  i^efiex  action.  Excita- 
tion of  the  vagus  fibres  in  the  stomach  by  cold  drink 
is  transmitted  to  the  vaso-motor  centre,  from  which 
slowing  of  the  pulse  and  change  in  its  curve  is  prob- 
ably evolved. 


—    26    — 

Warm  fluid  may  produce  nausea,  and  thus  lower 
the  innervation  and  result  in  diminished  arterial  ten- 
sion. 

The  incorporation  of  large  masses  of  fluid  with 
the  blood  must  produce  decided  changes  in  the  sys- 
tem. Water  is  doubtless  absorbed  chiefly  by  means 
of  the  veins  of  the  stomach,  and  its  rate  of  absorption 
is  governed,  according  to  Winternitz,  by  various  con- 
ditions. A  low  state  of  vascular  tension;  impoverish- 
ment of  the  blood  by  diarrhoea,  haemorrhages,  pro- 
fuse perspiration,  and  even  copious  urinary  excretions; 
a  feeble  percentage  of  salts  in  the  water;  the  presence 
of  free  alkali  in  it;  all  these  accelerate  the  absorption 
of  water  from  the  stomach  or  intestines. 

High  vascular  tension  and  plethoric  conditions 
of  the  system,  on  the  contrary,  inhibit  the  absorption 
of  water. 

It  follows  from  the  physiological  investigations 
of  Bocker  and  others  that  the  administration  of 
small  quantities  of  water  at  intervals  of  20  to  30 
minutes  for  a  long  time  will  increase  the  saturation  of 
the  tissues,  render  the  blood  column  heavier,  and  in- 
crease vascular  tension  and  pressure.  The  contrary 
effect  may  be  produced,  /.  ^.,  absorption  of  watery 
exudations,  etc.,  by  imbibition  of  large  quantities  of 
fluids  after  long  intervals  of  abstention  (6  to  8  hours). 
Clinical  observation  has  substantiated  these  deduc- 
tions. 

Tissue  meta?norphosis  (regressive  and  productive) 


—    27    — 

is  enhanced.  Indeed,  Boecker  says  :  "  There  is  no 
single  substance  which  so  rapidly  promotes  construc- 
tion, after  inaugurating  destruction,  and  which  re- 
juvenates the  system,  like  water.  In  the  institutions 
where  cold  water  is  used  externally  and  internally  we 
see  patients  whose  digestion  has  been  faulty  always 
ready  for  the  fork  exercises,  and  it  is  only  necessary 
to  drink  a  few  glasses  more  water  in  the  morning  in 
order  to  do  greater  honor  to  the  art  of  the  cook.  If 
the  effect  of  water  be  compared  to  that  of  mercury, 
the  rejuvenating  effect  of  the  former  becomes  clear; 
they  both  further  elimination  in  an  eminent  degree; 
the  prolonged  use  of  mercury,  however,  increases 
elimination  enormously,  and  constructive  action  suf- 
fers so  much  that  for  years  a  prolonged  feebleness 
remains.  Water  acts  differently.  It  interferes  with 
constructive  metamorphosis  only  if  its  use  is  too 
prolonged  and  combined  with  starvation.  But  as  a 
rule,  so  soon  as  it  is  discontinued,  reconstruction  be- 
gins more  energetically.  That  water  is  a  remedy  for 
the  rejuvenation  of  the  organism  deserves  to  be 
therapeutically  considered."  This  testimony  from  a 
physiologist  and  a  clinical  observer  is  entitled  to  re- 
spect, especially  as  it  has  been  physiologically  de- 
monstrated by  numerous  other  observers,  among 
whom  are  Hosier,  Lehman,  and  Glax.  These  have 
shown  that  the  imbibition  of  cold  water  acts  as  a 
diuretic,  and  increases  the  solid  constituents  of  the 
urine,    especially  urea.      Thus    it    is  evident  that  a 


—     28     — 

more  active  change  of  nitrogenous  material  is  inaugu- 
rated by  copious  water-drinking.  As  it  has  also  been 
shown  that  the  latter  is  followed  by  a  diminution  of 
uric  and  oxalic  acids,  and  an  increase  of  COg  and 
of  oxygen,  we  must  conclude  that  oxidation  is  more 
active  and  complete.  Again,  these  inorganic  salts  of 
the  urine,  which  are  products  of  regressive  metamor- 
phosis of  the  organs  and  muscles,  as  potash  salt,  phos- 
phates, and  sulphates,  are  shown  to  be  increased  by 
■drinking  large  quantities  of  water. 

It  is  true  that  this  interpretation  of  these  phe- 
nomena is  not  accepted  by  all  authorities,  there  being 
■still  some  doubt  whether  the  increase  of  urea  after 
copious  imbibition  of  water  is  the  result  of  increased 
utilization  and  destruction  of  albumen,  or  simply  the 
effect  of  a  more  thorough  flushing  of  the  vessels  by 
which  the  urea  is  more  rapidly  swept  out.  Be  this  as 
it  may,  it  cannot  be  denied  that  a  decided  increase  of 
water  imbibition  gives  rise  to  a  fluctuation  in  the 
formation  of  urea,  and  thus  a  change  is  produced  in 
the  system  which  must  produce  therapeutic  results. 
Water  that  is  drunk  is  not  simply  excreted,  but  some 
of  the  tissue  becomes  more  saturated  with  it,  especi- 
ally the  glands.  The  latter  are  forced  to  secrete 
more  abundantly,  and  the  heart  is  called  upon  to 
propel  a  larger  quantity  of  fluid;  the  kidneys  and 
skin  are  stimulated  to  increased  activity.  And  all 
this  is  accomplished  in  the  very  innermost  parts  of 
the  body,  far  away  from  reflex  influences,  which  are 


—    29    — 

the  chief  agencies  by  which  the  external  use  of  water 
acts. 

Peristalsis  is  increased  by  imbibition  of  cold 
water.  This  may  be  observed  readily  in  emaciated 
persons  and  in  the  expulsion  of  gases  from  the  rectum. 

Increased  biliary  secretion  has  also  been  noted  by 
Lehman  and  others.  Horvath  has  proved  by  passing 
streams  of  water  of  various  temperatures  (from  66°  to 
io6°  F.)  that  peristalsis  is  stimulated,  and  Roehrig 
has  demonstrated  by  actual  experiment  that  intestinal 
irrigation  increases  bile  secretion  more  than  the  injec- 
tion of  water  into  the  veins.  Thus  is  the  treatment 
introduced  by  Krull  in  catarrhal  jaundice  established 
upon  physiological  principles. 

We  may  conclude  from  the  results  of  many  ex- 
periments, whose  details  space  does  not  admit  of  re- 
counting, that,  inasmuch  as  an  increased  absorption 
of  water  into  the  veins  must  give  the  heart  and  glands 
more  work  to  do,  we  have  in  the  administration  of 
large  quantities  of  water,  especially  of  cold  water,  a 
valuable  remedy  for  stimulating  various  functions, 
which  may  be  utilized  clinically  if  the  rationale  of  its 
action  is  not  lost  sight  of. 

If  it  is  remembered  that  the  stimulus  is  felt  by 
the  organs  themselves,  and  does  not  depend,  when 
the  secretions  are  involved,  so  much  upon  reflex  nerve 
activity,  the  internal  use  of  water  will  be  preferably 
applied  in  many  cases  in  which  its  external  use,  which 
demands  considerable  power  of  reaction,  would  fail. 


_  30  — 

The  temperature-reducing  and  gland-stimulating 
effect  of  copious  water  imbibition  has  been  utilized  in 
disease  recently  by  Meigs,  Cantani,  Dujardin-Beau- 
metz,  Debove,  and  Sahli,  as  will  be  shown  in  the  clin- 
ical part  of  this  work.  Suffice  it  here  to  maintain  the 
connection  between  the  physiological  and  therapeutic 
lines,  by  citing  the  practice  of  Cantani,  who  reduces 
temperature  slowly  but  surely  by  copious  enemata  and 
drinking  of  cold  water,  and  the  practice  of  Beaumetz, 
who  promotes  diuresis  and  elimination  of  the  pro- 
ducts of  organic  disintegration  by  copious  libations  of 
water,  and  the  practice  of  Debove,  who  administers, 
instead  of  drugs  in  typhoid  fever,  six  ounces  of  cold 
water  every  two  hours  for  the  purpose  of  washing  out 
the  poison.  In  this  method  of  hydrotherapy,  as  in 
the  external  method,  the  empirics  have  done  much  to 
bring  its  use  into  disrepute  by  the  swilling  to  which 
they  have  subjected  their  patients.  It  must  be  evi- 
dent to  any  unprejudiced  observer  who  understands 
the  rationale  of  water-drinking  that  its  excessive  use 
must  overburden  the  system,  and,  if  the  latter  be  al- 
ready enfeebled,  must  tend  to  cripple  the  organs  it  is 
intended  to  relieve. 

EXTERNAL    USE    OF    WATER. 

This  being  the  most  important  mode  of  applica- 
tion in  hydrotherapy,  a  thorough  study  of  its  physio- 
logical effect  when  applied  to  the  periphery  is  of  great 
importance. 


—  31  — 

Aside  from  certain  minor  effects,  such  as  the 
antiseptic  and  cleansing,  we  may  divide  the  essential 
action  of  water  into:  ist,  that  evolved  by  its  tempera- 
ture effects;  and,  2d,  by  its  mechanical  impact. 

As  a  vehicle  for  the  absorption  and  transmission 
of  temperature  variation  to  the  periphery,  and  thence 
by  direct  or  reflex  action  to  the  centres  of  the  body, 
water  is  a  phenomenally  useful  agent. 

That  it  possesses  an  enormous  capacity  of  ab- 
sorbing heat  without  being  itself  much  elevated,  and 
of  giving  off  heat  without  losing  itself  very  materially, 
has  been  frequently  demonstrated  by  experiments. 
The  quantity  of  heat  required  to  raise  the  tempera- 
ture of  I  lb.  of  water  34°  suffices  to  elevate  to  the 
same  temperature  2  lbs.  of  oil  of  turpentine,  8  lbs.  of 
iron,  or  S3  lbs.  of  mercury.  Again,  one  gramme  of  iron 
at  32°  may  be  elevated  to  130°  F.  by  the  same  quan- 
tity of  water  at  140°,  while  the  latter  only  loses  43°; 
while  one  gramme  of  iron  at  140°  F.  will  elevate  one 
gramme  of  water  at  32"  only  to  43°,  with  a  loss  of 
130°. 

The  enormous  physical  change  to  which  water 
may  be  subjected  at  different  temperatures  enhances 
its  value  as  a  flexible  therapeutic  agent,  whose  effects 
must  be  carefully  studied.  At  32°  F.  water  solidifies, 
while  at  212°  under  ordinary  atmospheric  pressure  it 
becomes  elastic,  attaining  a  volume  1,700  times  greater. 

When  it  is  considered  how  easily  the  temperature 
of  water  can  be  varied  by  the  judicious  application  of 


—  32  — 

ice  or  heat,  how  its  application  may  be  limited  to  the 
most  minute  portion  of  the  body  or  be  made  to  its 
entire  periphery,  and  how  its  local  temperature  effects 
may  be  varied  in  different  parts  of  the  body  at  the 
same  time  or  at  different  times,  its  immense  value  as 
a  therapeutic  agent  must  be  appreciated,  after  these 
effects  are  carefully  studied,  as  we  propose  now  to  do. 

By  means  of  low  and  high  temperatures  we  may 
produce  positive  irritation,  and  by  means  of  moderate 
temperatures  we  may  neutralize  irritation  already 
existing;  thus  we  have  a  scale  of  stimulating  or  sooth- 
ing effects,  for  which  we  look  in  vain  among  medicinal 
agents. 

As  Kroeger  has  aptly  put  it,  just  as  the  eye  per- 
ceives certain  waves  of  ethereal  atoms  as  impres- 
sions of  light,  so  do  the  organs  of  temperature  per- 
ception, the  peripheral  endings  of  the  sensory  nerves, 
experience  definite  waves  of  body  atoms  as  percep- 
tions of  heat  and  cold.  This  conception  renders  in- 
telligible all  empirically  established  facts  which  are 
observed  in  the  effect  of  various  temperatures  upon 
the  organism. 

EFFECTS    OF    TEMPERATURES. 

That  temperature  exercises  a  potent  influence 
upon  living  matter  is  a  trite  physiological  fact.  That, 
cold  diminishes  vital  activity  and  heat  enhances  it 
needs  but  a  simple  reference  to  emphasize  the  appli- 
cation of  these  well  recognized  principles  to  thera- 


—  S3  — 
peuticst  Smooth  muscular  fibres  are  positively  made 
to  contract  under  cold  and  expand  under  heat,  within 
certain  limits.  This  physiological  fact  alone  renders 
it  evident  how  powerfully  we  may  influence  heat  pro- 
duction, which  depends  upon  muscular  activity,  and 
consequently  tissue  change,  which  is  interwoven  with 
heat  production,  and  indirectly  by  these  means  all 
other  functions,  by  any  measure  which,  like  water, 
gives  us  complete  control  over  muscular  activity. 

Although  it  is  difficult  to  separate  the  thermic 
from  the  mechanical  effect,  it  is  useful  to  study  each 
separately  as  far  as  it  will  admit.  Cold  and  heat 
may  be  regarded  as  nerve  irritants  whose  intensity  is 
in  proportion  to  the  difference  of  temperature  be- 
tween the  part  receiving  the  impression  and  the  agent 
conveying  it. 

There  is,  however,  a  limit  to  the  therapeutic 
application  of  thermic  agents.  Both  extremes  of 
temperature  become  painful  and,  as  is  well  known, 
may  destroy  sensibility  and  eventually  vitality  also. 

Recent  investigations  by  Donath  (Archiv.  fur 
Psychiatric,  1884,  xv)  have  placed  the  painful  cold 
impressions  in  different  parts  of  the  body  of  healthy 
persons  as  varying  from  12°  to  37°  F.  In  different 
individuals  the  painful  impression  from  cold  varies 
between  29°  and  73°  F.  Painful  heat  impressions 
also  vary  according  to  the  parts  applied  to  between 
98^  and  126°  F.;  the  variations  in  individuals  being 
between  36°  and  88°  F.     The  upper  and  lower  limits 

3  EEE 


—  34  — 
of  heat  impression  for  various  points  in   the  skin  are 
147°  and  95°  F.,  respectively. 

There  exists  great  latitude  in  the  sensibility  to 
cold  and  heat  impressions  in  different  parts  of  the 
body,  and  even  in  the  same  parts  at  different  times, 
due  to  the  condition  of  the  nervous  system  and  the 
circulation  at  the  time  of  observation. 

It  has  been  ascertained  by  Blix  and  Goldscheider 
that  there  are  special  terminal  nerves  in  the  skin, 
devoted  to  the  perception  of  heat  and  cold  and  of 
pressure,  and  that  the  perception  ot  cold  is  rapid  and 
lightning-like,  while  that  of  heat  is  more  deliberate 
and  diffused.  Warming  and  cooling  of  the  skin  re- 
duces the  response  of  the  latter  to  both  heat  and  cold, 
but  each  enhances  the  response  of  the  other  to  op- 
posite temperature  effects. 

Thermic  irritants  induce  changes  of  innervation 
not  only  at  the  point  of  contact,  but  also  in  sensory 
tracts,  in  the  nerve  centres,  and  in  all  motor  and 
trophic  fibres  connected  with  them  whenever  they 
fall  within  the  sphere  of  irritation,  either  by  trans- 
mitted or  reflex  action.  The  effect  upon  motor  fibres 
is  not  to  be  regarded  only  as  reflex,  for  even  at  the 
point  of  application  there  are  everywhere  numerous 
networks  of  ganglia,  which  may  perform  the  function 
of  nerve  centres  within  the  immediate  sphere  without 
depending  upon  impulses  from  the  brain  or  spinal  cord. 
This  makes  plain  many  local  effects,  which  seem  to 
arise    independently    of    the    higher    nerve    centres. 


—  35  — 
There  can  be  no  doubt  that  thermic  irritants,  con- 
veyed by  water  or  otherwise,  exert  their  effect'  upon 
the  innervation.  The  rapidity  of  their  action  alone 
would  prove  this.  But  clinical  experience  demon- 
rstrates  it  in  the  most  forcible  manner. 

Whoever  has  witnessed  the  revivification  of  a 
fainting  person  by  a  dash  of  cold  water,  how  the 
color  returns  to  the  pallid  cheek,  how  the  glazed  eyes 
brighten  and  consciousness  returns,  must  be  con- 
vinced that  only  through  impressions  upon  the  sensory 
aerve  endings,  conveyed  to  the  nerve  centres,  could 
such  rapid  and  positive  effects  be  initiated.  That 
-cold,  though  the  most  familiar,  is  not  alone  in  this 
powerful  influence  I  have  demonstrated  to  my  satis- 
faction. 

In  a  case  of  carbolic  acid  poisoning,  with  suicidal 
intent,  in  which  I  had  the  assistance  of  Dr.  Dillon 
Brown,  hot  water  proved  more  efficient  than  cold  in 
arousing  flagging  vitality. 

That  extreme  heat  and  cold  may  destroy  sensa- 
tion, even  to  complete  death  of  the  part,  is  an  undis- 
puted fact.  But  it  is  not  so  generally  known  that 
cold  applied  to  a  nerve  trunk  may  produce  anaesthesia, 
and  even  paresis  of  its  peripheral  fibres. 

Waller  applied  ice  to  the  ulnar  nerve  in  its  super- 
ficial position  at  the  elbow  joint,  and  obtained  at  first 
hyperaesthesia,  later  complete  anaesthesia  of  its 
branches  and  abolition  of  response  in  the  muscles 
supplied  by  them.     We  are  indebted  to  our  own  Weir 


_  36  - 

Mitchell  for  some  valuable  investigations  upon  the- 
subject.  He  demonstrated  (quoted  by  Winternitz) 
that  anatomical  changes  may  be  produced  by  intense 
cold  applied  to  the  nerves,  such  as  congestion  with  or 
without  sanguineous  exudations.  Briefly  applied,  cold 
produces  a  rapidly  passing  congestion,  without  leaving 
traces  behind,  but,  if  prolonged,  the  nerve  increases  in, 
volume,  chiefly  by  the  dilatation  of  its  blood-vessels. 
There  may  be  actual  apoplectic  effusions  in  the  struc- 
ture of  the  nerve,  producing  more  or  less  paralysis  in 
the  parts  supplied  by  it,  but  they  usually  disappear, 
although  some  of  the  nerve  fibres  may  degenerate. 

Thus  we  may  account  for  some  cases  of  acute- 
neuralgia,  myelitis,  and  acute  spinal  paralysis  following 
great  temperature  effects. 

Upon  one  point  all  observers  are  agreed,  viz., 
that  the  effect  of  the  thermal  impact  is  in  proportion 
to  its  duration,  viz.,  that  an  evanescent  application  excites ^ 
while  a  prolonged  one  depresses. 

This  is  of  immense  importance  in  clinical  hydro- 
therapy, as  will  be  shown. 

Another  element  of  great  clinical  importance  has 
been  justly  emphasized  by  Winternitz.  The  sudden- 
ness or  deliberateness  of  the  excitation  influences  the 
susceptibility  of  the  part  to  which  it  is  applied;  the 
former  produces  tumultuous,  the  latter  more  calm 
results,  just  as  in  the  case  of  the  sudden  and  gradual 
application  of  a  bright  light  to  the  eyes.  Daily  ob- 
servation confirms  the  axiom,  but  there  is  a  difference 


—  37  — 
whether  the  transition  be  from  warm  to  cold,  or  vice 
versa.  In  the  former  case  there  is  a  more  energetic 
reaction,  because  the  nerves  are  in  a  state  of  height- 
ened excitability,  and  this,  too,  is  utilized  in  the  prac- 
tice of  the  French  hydrotherapists,  who  precede  many 
of  their  douches  by  hot  air  baths. 

It  must  also  be  remembered  that,  as  Urbant- 
schitsch  has  shown,  there  are  physiologically  inter- 
changing effects  of  irritation  in  various  sensory 
spheres,  i.e.^  excitations  in  one  sphere  may  produce 
similar  effects  in  another.  That  the  effect  of  tem- 
perature impressions  upon  the  peripheral  nerves  may 
be  far-reaching  is  thus  physiologically  demonstrated. 

.INFLUENCE     OF     THERMIC      APPLICATIONS      UPON      THE 
CIRCULATION. 

The  impact  of  cold  conveyed  by  any  medium  to 
the  skin,  as  is  matter  of  common  observation,  induces 
pallor  and  shriveling  of  the  skin.  Many  physiologists 
have  demonstrated  that  this  is  due  to  contraction  of  the 
circular  fibres  of  the  cutaneous  vessels,  by  which  the 
blood  is  driven  out.  In  accordance  with  the  physio- 
logical law  that  striated  muscular  fibres  contract  and 
dilate  slowly,  the  contraction  of  the  muscular  struc- 
ture of  the  skin  is  followed  by  a  deliberate  relaxation. 
The  vessels  not  only  resume  their  normal  size,  but 
even  are  dilated  beyond  it,  so  that  more  blood  is 
received  by  them. 

Following  the  process  more    minutely,    we   find 


-38- 
that  by  intensely  low  temperatures  the  circulation  in 
the  capillaries  is  at  first  accelerated  and  the  number 
of    blood    corpuscles    diminished,    when     the    part 
becomes  pale. 

Quickly  following  this  acceleration  there  is  a 
stasis  in  the  capillaries,  while  in  the  smaller  veins  and 
arteries  the  slowing  of  the  circulation  is  followed  by 
brief  and  rapid  oscillations,  which  become  slower  and 
more  infrequent.  Slowly  the  vessels  become  more 
pale,  less  transparent,  and,  finally,  the  movements 
cease,  until  the  vessel  is  blocked  and  occluded. 

When  the  cold  is  less  intense  and  more  pro- 
longed, there  ensues  a  retardation  of  the  stream  in 
the  smaller  capillaries,  while  it  becomes  more  active 
in  the  larger  vessels,  which  now  dilate.  If,  however, 
the  application  is  continued,  the  larger  vessels  are 
also  contracted  and  blocked.  A  collateral  hyperae- 
mia  in  neighboring  parts  is  the  result,  which  produces- 
more  rapid  circulation  in  them. 

It  is  not  difficult  to  deduce  the  most  important 
physiological  changes  as  the  result  of  this  energetic 
influence  of  cold  upon  the  vessels,  as  will  appear 
farther  on. 

The  return  of  blood  to  the  previously  contracted 
vessels  is  probably  not  due,  as  is  commonly  supposed,, 
to  a  relaxation  of  the  coats  of  the  vessels.  When  the 
vessels  dilate  after  a  brief  application  of  intense  cold^ 
together  with  decided  mechanical  impact  derived 
from  pressure  under  which  the  stream  of  cold  water 


—  39  — 

strikes  the  part,  the  dilatation  following  the  latter 
cannot  be  a  passive  process,  but  is  more  probably  the 
result  of  an  excitation  of  the  inhibitory  nerves,  which 
overcomes  the  action  of  the  vaso-constrictors.  This 
is  true  of  all  vascular  dilatation  following  the  impact 
of  cold. 

REACTION. 

As  has  been  mentioned  above,  blanching  of  the 
surface  is  the  immediate  effect  of  the  application  of 
cold.  This  is,  however,  quickly  followed  by  an  active 
congestion,  and  may  eventuate  in  stagnation  of  the 
circulation.  The  superficial  vessels  receiving  direct 
impact  dilate  most  quickly  after  the  primary  contrac- 
tion has  passed.  They  become  distended  with  blood, 
but,  since  the  continued  application  of  cold  renders 
the  capillary  circulation  sluggish  in  the  parts  subject- 
ed to  it,  the  veins  respond  less  actively  to  the  excitant 
influence  of  cold,  and,  their  contraction  being  more 
slow,  their  dilatation  is  correspondingly  slow.  Thus 
it  comes  about  that  the  blood  accumulates  at  the 
point  of  application  of  the  cold,  which  becomes  tur- 
gid at  first,  and  later  cyanotic.  This  effect,  however, 
.but  slowly  reaches  the  deeper-seated  vessels,  whose 
contraction  would,  as  is  well  known,  materially  influ- 
ence all  vessels  to  which  they  are  tributary.  If  this 
happens,  or  if  cold  is  applied  directly  to  the  large  ves- 
sels, however,  their  tributaries  receive  a  smaller  sup- 
ply of  blood,  and  they  accommodate  themselves  to 
the  change  by  diminishing  their  calibre.     The  result 


—  40  — 

is  an  increase  of  resistance,  viz.,  tone,  which  can  be 
readily  demonstrated  by  the  sphygmograph — a  tone 
in  which  every  part  of  the  arterial  circulation  partici- 
pates if  the  entire  periphery  is  subjected  to  the  cold. 
The  condition  of  the  pulse  indicates  clearly  that  the 
local  hypersemia  resulting  from  the  thermic  irritants 
(within  reasonable  limits)  is  not  an  evidence  of  ex- 
haustion or  paralysis,  but  points  distinctly  to  a  height- 
ened tension  in  the  vascular  system.  It  is  scarcely 
necessary  to  emphasize  the  physiological  fact  that 
these  effects  are  traceable  to  the  nervous  system,  and 
that  change  of  temperature  can  thus  be  readily  in- 
duced by  change  in  the  blood  supply.  But  it  must  be 
remembered  that  not  alone  upon  the  circulation  may 
we  thus  energetically  act,  but  also  upon  the  innerva- 
tion. The  effect  of  the  application  of  cold  to  the 
large  nerve  trunks  is  well  known,  and  has  been  re- 
ferred to  above. 

Thus  it  seems  clearly  established  that  the  most 
powerful  effects  may  be  incited  by  the  application  of 
cold,  by  reason  of  its  effect  on  the  calibre  of  the  ves- 
sels. 

EFFECTS    UPON     DISTANT    PARTS. 

An  important  result  of  thermic  applications  to 
the  periphery  is  obtained  in  their  effect  upon  parts 
not  directly  in  contact  with  them.  Since  the  impulse 
conveyed  by  the  heart  to  the  blood  stream  continues 
unabated,  the  contraction  and  subsequent  dilatation 
of  the  parts    in    immediate    contact   induces    certain 


—   41    — 

•changes,  by  which  vascular  accommodation  is  accom- 
plished. 

If  the  blood  is  driven  out  of  the  narrowed  ves- 
sels, it  finds  entrance  into  the  collateral  circulation. 
As  a  result  we  have  collateral  hyperaemia,  accom- 
panied by  increased  tension  and  rise  of  temperature. 
The  vessels  of  those  parts,  again,  which  receive  this 
increased  blood-supply  contract  more  vigorously,  and 
force  the  blood  which  has,  by  reason  of  local  or  gen- 
eral pathological  conditions,  accumulated  within 
them,  to  move  on  and  give  place  to  the  more  active 
current.  This  change  in  the  blood-current,  which  has 
been  demonstrated  by  actual  experiment,  is  capable 
of  depleting  congested  organs,  of  restoring  their 
normal  tone,  and  of  conveying  to  the  diseased  organ 
material  for  renovating  its  function.  Moreover,  by 
this  increase  of  the  local  circulation,  materies  morbi, 
-elements  of  retrograde  metamorphosis,  and  detritus  of 
various  kinds,  whose  presence  has  seriously  menaced 
the  activity  of  the  suffering  organ  and  the  life  of  the 
patient,  may  be  removed. 

This  brief  explanation  of  the  possibilities  of 
hydriatic  procedures  and  of  their  rationale  lends  color 
to  the  claim  of  such  excellent  clinicians  as  Semmola 
(Klinische  Therapie,  1890,  translated  into  German, 
with  preface  by  Prof.  Nothnagel)  that  "  in  visceral 
troubles  which  defy  all  treatment  because  they  are 
favored  by  special  alterations  of  tissue  change,  ,the 
physician  may  accomplish  in  many  cases  a  true  and 


—  42   — 

real  cure  by  endowing  all  the  functions  of  the  organ- 
ism with  the  highest  activity,  by  the  aid  of  hydro- 
therapy." Medicinal  agents  are,  as  every  experi- 
enced physician  knows,  utterly  impotent  in  such  cases 
to  endow  organs  suffering  from  languid  blood  supply 
with  vigor  by  the  increased  afflux  of  blood  and  heat 
and  nerve  force.  This  may  be  accomplished  readily 
by  the  retrostasis  which  invariably  results  when  blood 
is  driven  from  one  part  of  the  body  into  another,  not 
by  severe  local  irritants,  blisters,  cautery,  etc.,  but  by 
processes  which  imitate  the  physiological  closely,  and 
which  are  under  complete  control  of  the  hydrothera- 
peutist. 

Like  all  agents  that  are  powerful  for  good,  how- 
ever, this  method  may  produce  irreparable  damage. 
George  Johnson,  of  London,  has  shown  that  transient 
albuminuria  may  thus  be  produced,  and  Winternitz 
cites  a  case  in  which  transient  hsemoglobinuria  was 
due  to  that  cause.  Vessels  that  have  become  atherom- 
atous may  be  ruptured  and  life  destroyed  in  the 
same  way.  Due  regard  must,  therefore,  be  had  in 
elderly  people,  and  in  those  less  mature  also,  to  the 
condition  of  the  vessels,  ere  this  powerful  agency  of 
retrostasis  is  called  into  action.  The  experienced 
hydrotherapeutist  endeavors  to  tone  up  threatened 
parts  by  preceding  brief  or  enduring  cold  applica- 
tions, and  by  taking  care  that  all  procedures  are  fol- 
lowed by  distinct  reaction  to  the  surface. 

All  applications  of  cold  to  the  periphery^  even  if 


—  43  — 

they  are  followed  by  dilatation  of  the  peripheral  ves- 
sels in  full,  cause  an  increase  of  blood-pressure.  The 
contraction  of  the  arterial  capillaries  induces  primarily 
an  acceleration  of  the  blood  stream  from  the  arteries 
to  the  veins  by  way  of  the  capillaries.  The  return  of 
the  blood  into  the  nervous  system  must  be  accelerated 
by  this  increased  vis  a  tergo.  The  deepening  of  the 
respiration  which  also  results,  and  which  will  be  re- 
ferred to  below,  increases  the  rapidity  of  the  circula- 
tion of  the  small  vessels,  and  induces  an  increased 
and  accelerated  return  flow  of  blood  into  the  left 
auricle,  a  slower  and  more  vigorous  systole,  and  more 
active  filling  of  the  arterial  system;  hence,  a 
heightened  blood  pressure  in  it. 

The  sphygmograph  demonstrates  that  the  dilata- 
tion of  the  peripheral  vessels  which  ensues  upon  re- 
action is  not  accompanied  by  a  loss  of  tone  and  is  not 
passive,  but  is  probably  due  to  an  excitation  of  the 
inhibitory  nerves.  This  is  confirmed  by  the  opposite 
effect  which  hot  vapor  baths  produce  upon  sphygmo- 
graphic  tracings.  These  show  plainly  a  reduction  of 
tone,  diminished  tension,  and  great  dicrotism. 

It  may  be  accepted  as  a  demonstrated  fact  that 
cold  enhances,  while  heat  lowers,  the  tone  of  the 
vessel  walls,  although  both  are  followed  by  vascular 
dilatation  of  the  surface  vessels.  In  the  former, 
however,  we  have  an  accelerated  and  increased  pass- 
age of  blood,  with  the  vessels  under  high  tension; 
while  in  the  latter  we  have  the  vessels  under  low  ten- 


—  44  — 
sion,  and  the  walls  relaxed  and  dilated,  owing  proba- 
ably  to  a  diminution  in  their  elasticity.  That  these 
last  must  sooner  or  later  produce  a  hyperaemia  is 
evident;  hence,  it  is  important  to  distinguish  these 
physiological  differences  between  cold  and  warm 
application,  which  primarily  do  not  differ  materially 
but  eventually  are  totally  at  variance. 

PRACTICAL    DEDUCTIONS. 

The  practical  deduction  from  all  the  investigations 
on  this  subject  is  clear,  that,  wherever  we  aim  to  reduce 
blood  pressure  with  passive  hyperaemia,  warm  water 
should  be  applied;  whenever  we  desire  to  produce  in- 
creased blood  pressure  with  active  hyperaemia,  without 
loss  of  that  contractility  which  is  so  essential  to  a  nor- 
mal healthful  circulation,  we  should  resort  to  cold 
water.  That  the  tension  of  the  tissues  and  vessels 
exercises  the  most  potent  influence  upon  the  local  cir- 
culation in  the  blood  and  lymph  vessels  has  been  con- 
vincingly demonstrated  by  Landerer  in  Volkmann's 
Sammlung,  p.  259. 

If,  then,  we  may  by  varying  applications  of  heat 
and  cold  powerfully  affect  the  tension  of  the  tissues 
and  vessels,  it  is  but  reasonable  to  deduce  that  by 
these  applications  we  may  overcome  many  inflam- 
matory conditions.  Clinical  evidence  of  such  eft'ect 
is  abundant.  The  increase  of  urinary  flow,  which  is 
commonly  observed  after  the  cold  bath,  both  in  health 
and  disease,  and  which  I  have  often  seen  exemplified 


—  45  — 
in  typhoid  fever,  is  another  evidence  of  the  increase 
of  blood  pressure  after  cold  application.  Not  alone, 
however,  by  direct  vascular  effect  upon  the  continuity 
of  the  vessels  may  this  influence  upon  the  circulation 
be  produced.  Formerly  this  was  regarded  as  the 
only  channel  of  action  of  remedies  which  produce 
local  external  hyperemia.  It  was  supposed  that  the 
accumulation  of  blood  on  the  surface  after  bHsters 
or  rubefacients  withdrew  blood  whose  fluxion  to  in> 
ternal  organs  was  pathological,  and  thus  proved  anti- 
phlogistic. This  fallacy  was  exposed  by  the  investiga- 
tions of  Naumann,  which  have  become  classical. 

REFLEX    EFFECTS. 

Naumann  has  demonstrated  clearly  that  the  effects 
of  peripheral  irritants  upon  the  circulation  within  the 
body  were  really  reflex.  He  separated  the  head  of  a 
frog  from  the  body,  leaving  them  connected  by  the 
medulla  oblongata  only.  He  next  severed  one  leg, 
after  preventing  loss  of  blood  by  tying  the  vessels  so  as 
to  leave  it  connected  with  the  body  by  the  sciatic  nerve. 
Now  he  applied  thermal,  chemical,  and  electric  stimuli 
to  the  foot  of  the  partially  severed  leg,  while  he  ob- 
served under  the  microscope  the  mesentery  of  the  frog. 
Shortly  after  gentle  irritation  of  the  peripheral  endings 
of  the  sciatic  nerve  in  the  foot,  the  circulation  in  the 
vascular  network  of  the  lungs  and  mesentery  was  ac- 
celerated, and  resumed  the  former  condition  slowly 
after  the  withdrawal  of  the  irritant.     A  more  severe 


-  46  - 

irritation  produced  retardation  of  the  flow,  and  even 
stasis  occurred,  as  if  the  heart  had  become  temporarily 
paralyzed.  A  strong  irritant  produced  dilatation,  a 
feeble  one  constriction  of  the  vessels.  The  effect  of 
these  peripheral  irritations  upon  the  heart  was  also 
noted.  A  strong  irritation  of  the  skin  weakened  its 
circulation;  a  feeble  irritant  strengthened  it.  As 
there  was  no  possible  vascular  or  nerve  channel  from 
the  part  irritated  to  the  part  thus  visibly  affected,  and 
as  the  cutting  of  the  spinal  cord  entirely  prev^ented 
this  result,  the  conclusion  is  inevitable  that  the  effect 
is  entirely  reflex.  Hot  water  acted  precisely  in  the 
same  manner  as  other  irritants.  Naumann  continued 
his  investigations  upon  warm-blooded  animals  and 
upon  man  with  the  same  result,  and  announced  his 
conclusions  as  follows: 

1.  The  action  of  epispastics  is  essentially  pro- 
duced by  means  of  reflex  action  through  the  central 
organ. 

2.  These  agents  exert  considerable  influence 
upon  the  activity  of  the  heart  and  vessels. 

3.  In  proportion  to  the  irritability  of  the  indi- 
vidual, powerful  continuous  stimuli  lessen  the  activity 
of  the  heart  and  vessels  and  weaken  contraction,  the 
vessels  becoming  dilated  and  the  circulation  slower. 

4.  Relatively  weak  stimulation  increases  the 
activity  of  the  heart  and  vessels,  strengthens  cardiac 
contraction,  narrows  the  vessels,  and  accelerates  the 
circulation. 


—  47  — 

5.  The  changes  produced  in  the  body  by  long- 
continued  cutaneous  stimulation  last  a  considerable 
time  after  the  conclusion  of  the  same,  as  a  general 
rule;  the  more  enduring  the  stimulation  applied,  the 
longer  they  will  last,  and  in  a  healthy  person  will 
often  still  be  perceived  after  the  lapse  of  from  half 
to  three-quarters  of  an  hour  from  the  conclusion  of 
the  stimulation. 

6.  The  relaxation  of  the  pulse  which  follows  a 
more  powerful  cutaneous  stimulation  often  attains  its 
maximum  during  the  stimulation,  but  frequently  only 
after  the  conclusion  of  the  same. 

7.  The  excitant  action  of  a  relatively  weak  cu- 
taneous stimulation  likewise  continues  for  a  consider- 
able time  after  it  has  been  removed,  but  it  is  finally 
also  followed  by  a  relaxation,  only  that  this  appears 
much  later  and  in  a  less  degree  than  after  more 
powerful  cutaneous  stimulation. 

8.  As  a  consequence  of  a  stronger  cutaneous 
stimulation,  there  constantly  appears,  mostly  after  a 
longer  or  shorter  period  of  warming,  a  cooling  down 
of  the  body,  which  often  has  not  terminated  half  an 
hour  after  the  cessation  of  the  stimulus. 

9.  This  period  of  alteration  in  temperature  is  of 
varying  duration;  cooling  ofttimes  takes  place  during 
the  stimulation,  but,  as  a  rule,  only  after  its  conclu- 
sion. 


-  48  - 

EXPERIMENTAL    DEMONSTRATION    BY    VIVISECTION. 

Prof.  Max  Schiiller's  experiments  also  may  be 
cited  as  demonstrating  with  precision  the  influence  of 
thermic  applications  to  the  periphery  upon  the  circu- 
lation of  the  interior  of  the  body.  These  experiments 
are  of  great  importance,  since  they  were  made  alto- 
gether with  water.  Schiiller  trephined  rabbits,  care- 
fully exposing  to  view  the  vessels  of  the  pia  mater, 
without  disturbing  the  dura,  whose  transparency 
facilitates  such  observation.  He  carefully  noted  the 
normal  circulation  of  these  vessels,  and  ascertained 
that  even  simple  pressure  upon  the  belly  produced 
dilatation  of  the  veins,  and  sometimes  also  of  the 
arteries,  probably  through  mechanical  interruption  of 
the  venous  return  flow.  When  he  applied  pieces  of 
ice  upon  the  dura  mater,  he  observed  very  energetic 
contraction  of  the  veins  and  arteries,  which  continued 
half  a  minute  even  after  removal  of  the  ice.  When 
he  had  removed  the  superior  ganglion  of  the  sympa- 
thetic, the  ice  had  no  effect  upon  the  vessels.  The 
most  interesting  observation,  however,  was  that,  when 
he  placed  cold  wet  compresses  upon  the  belly  of  the 
rabbit,  the  vessels  of  the  pia  mater  invariably  dilated, 
cerebral  pulsation  became  more  pronounced  and  slower, 
and  respiration  was  deepened  and  slowed.  These 
phenomena  continued  a  short  time  after  removal  of 
the  compresses,  and  they  were  followed  by  transient 
narrowing  and  a  return  to  the  normal  calibre.  When 
warm  compresses  were  applied,  the  arteries  and  veins 


—  49  — 
of  the  pia  mater  contracted,  the  pulsations  became 
less  pronounced  and   more  frequent,  and   respiration 
more  shallow  and  rapid. 

By  changing  the  temperature  of  the  compresses 
these  changes  were  more  or  less  rapidly  produced.  A 
very  hot  compress  produced  the  same  effect  as  a  cold 
compress.  The  manifestations  were  also  observed, 
but  with  more  pronounced  effect,  after  immersion  of 
the  entire  body  into  cold  or  hot  water;  then  the  effect 
was  exactly  in  the  proportion  to  the  extent  of  surface 
immersed.  After  prolonged  immersion  in  cold  water 
a  narrowing  of  the  vessels  and  sinking  of  the  brain 
substance  ensued,  due,  doubtless,  to  the  reduction  of 
temperature  in  the  circulating  blood,  which  approxi- 
mated in  effect  to  that  produced  by  local  ice  applica- 
tion. The  vessels  of  the  ear  also  participated  in  the 
reflex  effect.  Immersion  in  warm  water  produced  a 
transient  dilatation,  which  was  followed  by  a  vigorous 
narrowing  of  the  vessels  and  sinking  of  the  brain  sub- 
stance. The  cerebral  movements  became  at  first 
accelerated,  afterward  slower  and  more  shallow,  finally 
becoming  more  rapid,  when  the  temperature  was 
elevated. 

Immersion  into  very  hot  baths  produced  effects 
similar  to  hot  compresses,  but  of  greater  intensity 
and  duration.  Under  the  cold  and  warm  douche  the 
cerebral  circulation  did  not  vary  greatly.  Cold  rec- 
tal enaemata  always  produced  a  moderate  dilatation 
of  the  cerebral  vessels.     Schiiller  has  placed  hydro- 

4    KEE 


—  0^  — 
therapy  under  lasting  obligations  by  the  pains  taken 
in  his  observations.  Winternitz  and  others  have  con- 
firmed on  the  human  subject  the  findings  of  Schuller  in 
the  rabbit.  By  means  of  the  pletysmograph  Winternitz 
was  enabled  to  measure  the  volume  of  various  parts, 
chiefly  the  arms,  of  individuals  who  were  subjected  to 
cold  applications  in  a  sitz  bath.  He  ascertained  that 
the  cold  affusion  produced  excitation  of  the  periphe- 
ral nerve  terminals,  which  in  turn  acts  by  reflex  upon 
the  vaso-motors.  Contraction  of  the  vessels  in  the 
vicinity  of  the  application  ensues;  the  blood  is  driven 
from  them,  thus  providing  other  vascular  areas  with 
more  blood,  which  increases  their  volume.  A  warm 
sitz  bath  produced  the  opposite  effect. 

PRACTICAL    DEDUCTIONS. 

These  valuable  deductions  enable  us  to  reason 
upon  the  various  and  somewhat  paradoxical  effects  of 
cold  and  hot  applications  Upon  the  heart,  as  the 
chief  agent  in  the  circulation,  thermic  applications  act 
more  powerfully,  not  only,  as  Naumann  has  observed, 
by  reflex  action,  but  also,  as  Winternitz,  Delmas,  and 
others  have  so  often  demonstrated,  by  narrowing  or 
dilating  the  peripheral  arteries,  and  thus  increasing  or 
diminishing  the  vigor  of  the  cardiac  contraction  by 
increasing  or  diminishing  the  resistance  to  it  at  the 
periphery. 

The  first  impression  of  cold  upon  the  sensory 
peripheral  nerve  endings  is  rapidly  conveyed  to  the 


—  51  — 
nerve  centre,  whose  response  is  manifested  by  the 
induction  of  more  rapid  contraction,  which  is  fol- 
lowed by  an  increase  of  vascular  tension.  Immedi- 
ately following  acceleration  of  the  cardiac  action  we 
observe  diminution  of  the  pulse  rate,  even  below  that 
existing  prior  to  the  application,  but  the  heightened 
tension  remains.  The  duration  of  this  effect  depends, 
however,  upon  whether  the  individuals  subjected  to 
the  application  remain  quiet  or  not.  If  absolute 
rest  follows  it,  the  heart's  action  slowly  becomes  less 
rapid;  if  muscular  exercise  follows  it,  the  p'ulse  sinks 
at  first,  and  afterwards  becomes  accelerated,  but  does 
not  lose  its  tension.  If  muscular  exercise  quickly 
follows  the  application  of  cold,  the  effect  upon  the 
circulation  will  be  more  manifest. 

Even  the  empirical  hydropaths  have  long  insisted 
.upon  the  value  of  sending  the  patients  out  in  the 
open  air,  and  in  Professor  Winternitz's  institute,  at 
Kaltenleutgeben,  it  is  a  rule  to  give  most  of  the  treat- 
ment immediately  after  rising,  when  the  reactive  capa- 
city of  the  patients  is  at  its  height,  and  sending  them 
out  to  walk  or  ride  before  breakfast  is  permitted. 
Thus  physiological  experiment  confirms  empirical  re- 
sults, and  enables  us  to  adapt  our  procedures  to  each 
individual  case  in  a  manner  far  excelling  that  of  drug 
treatment.  It  is  a  well  ascertained  law  in  physiology 
that  the  functional  activity  of  an  organ  is  always  ac- 
companied by  an  increased  flow  of  blood  through  it. 
The  quantity  of  blood  circulating  in  the  organ  being 


—  52  — 

increased,  a  proportionate  diminution  must  take  place- 
in  other  parts  and  organs,  diminishing  their  functional, 
activity  for  the  time  being. 

Although   much    additional  proof  could  be  fur- 
nished, we  have  dwelt  upon  the  manner  in  which  the 
influence  of  thermic  application  is  exercised  upon  the- 
circulation  with  sufficient  detail  to  convince  the  reader 
that  a  rational  basis  exists  for  it. 

INFLUENCE  OF  THERMIC    APPLICATIONS  UPON  THE 
RESPIRATION. 

Having  shown  clearly  how  thermic  applications 
may  influence  the  nervous  system  and  the  circulation^ 
it  is  not  difficult  to  demonstrate  the  effect  produced 
by  them  upon  the  respiration.  This  function  depends 
so  entirely  and  completely  upon  impulses  received 
from  the  central  nervous  system,  that  any  decided 
impression  made  upon  the  latter  must  affect  the  for- 
mer. Common  observation  quite  accords  with  this 
proposition.  The  deepened  respiration  indicated  by 
cold  affusion,  or  even  by  a  simple  dash  of  cold  water 
into  the  face  or  upon  any  other  sensitive  part,  is  a 
patent  illustration  of  how  energetically  this  influence 
may  be  exerted,  even  when  the  reflexes  are  dormant^ 
as  in  a  fainting  person.  In  the  cold  bath,  adminis- 
tered for  typhoid  fever,  there  is  so  deep  an  inspiratory 
effort  that  the  respiratory  muscles  are  unable  at  the 
first  moment  to  respond  to  the  stimulus.  The  patient 
gasps  for  breath  and  becomes  frightened,  and  the  same 


—  53  — 
thing  occurs  in  health  when  the  water  is  too  cold. 
This  spasmodic  effort  soon  passes  away,  the  muscles 
make  more  rapid  effort,  and  then  settle  down  to 
slower  action.  When  reaction  ensues  the  respiration 
is  found  to  be  deepened,  but  approximating  the 
normal  rhythm. 

Warm  applications,  on  the  contrary,  increase  the 
number  of  respirations.  The  warm  bath  renders 
them  more  shallow  and  frequent.  In  the  hot  air 
boxes  at  the  Montefiore  Home  the  respirations  are 
increased  from  20  to  30  per  cent.,  and  sometimes 
become  so  shallow  that  the  patient  is  panting. 

^INFLUENCE    OF    THERMIC     APPLICATIONS    UPON    TISSUE 
CHANGE. 

Carl  Voit,  Finkler,  Duke  Carl  Theodore,  Lieber- 
meister,  and  others  have  demonstrated  by  actual  ex- 
periment that  in  the  only  reliable  test,  the  excretion 
of  COg  and  absorption  of  oxygen,  oxidation  is  cer- 
tainly enhanced  by  cold,  and  diminished  by  warmth, 
so  long  as  the  temperature  is  approximately  constant. 
The  sinking  of  temperature  even  slightly  below  the 
normal  is  at  once  followed  by  retardation  of  the  pro- 
cesses of  combustion,  and  a  similar  rise  of  tempera- 
tur  produces  the  reverse  effect.  The  seemingly 
paradoxical  effects  of  thermic  applications  are  thus 
explained:  Cold  may  exercise  the  same  influence 
upon  tissue  change  as  warmth,  accoi'ding  to  the  degree 
oi  temperature  applied.    An  increase  of  tissue  change 


—  54  — 
under  cold,  as  Pfliiger  and  others  have  shown,  oecur& 
as  the  result  of  the  excitation  of  the  sensory  nerves 
by  it,  the  degree  of  tissue  change  accelerated  depend- 
ing upon  the  degree  of  muscular  contraction  by  it  as 
a  reflex  effect.  This  is  very  important,  and  may  be 
regarded  as  axiomatic. 

The  increased  metabolism,  resulting  as  a  reflex 
effect  from  the  influence  of  cold,  is  chiefly  manifested 
m  non-nitrogenous  material;  there  is  no  increased 
consumption  of  albumen.  The  tissue  metamorphosis 
following  the  direct  influence  of  cold,  on  the  contrary, 
is  similar  to  that  produced  by  raising  the  body  tem- 
perature, either  artificially  or  in  fever.  Heat  abstrac- 
tion, as  produced  by  hydriatic  procedures,  induces  an 
increase  of  nitrogenous  tissue  change  in  the  course  of 
the  temperature  elevation  incidental  to  the  period  of 
reaction.  These  may  be  graded  according  to  the 
grade  of  reaction,  which  is  often  dependent  upon  the 
heat  abstraction  producing  it. 

All  experiments  have  demonstrated  again  and' 
again  that  an  increase  of  urine  and  diminution  of  its 
specific  gravity  result  from  cold  baths.  This  would 
only  indicate  a  more  complete  excretion  of  the  pro- 
ducts of  retrograde  metamorphosis  of  nitrogenous 
matters,  not  an  increased  formation.  The  increased 
elimination  of  urine  is  probably  chargeable  to  the 
change  of  the  circulation  and  perspiration.  This  is 
not  the  case  in  the  changes  produced  in  the  urine  by 
the  elevation  of  temperature   incidental   to  the   period 


—  55  — 
of  reaction  following  applications  of  cold.  Juergen- 
sen  and  others  have  shown  in  their  studies  of  body 
heat  that  in  six  to  eight  hours  after  a  cold  bath  the 
urine  presents  a  higher  specific  gravity  and  contains 
more  urea  than  it  does  immediately  after  the  applica- 
tion. 

These  investigations  lend  a  certain  amount  of 
probability  to  the  assertion  that  low  temperatures 
acting  upon  the  body  produce  an  increase  of  oxygen 
absorption  and  COg  excretion.  If  the  bodily  tem- 
perature is  reduced  by  the  application  of  cold,  oxygen 
absorption  is  diminished,  as  well  as  carbonic  oxide 
excretion.  While  warmth  also  diminishes  the  eleva- 
tion of  bodily  temperature,  external  heat  increases  the 
respiratory  function,  as  I  have  shown  above,  from  ex- 
periments in  the  Montefiore  Home.  With  this  an  in- 
creased excretion  of  nitrogen  ensues. 

PRACTICAL    DEDUCTIONS. 

Winternitz  justly  cites,  as  an  evidence  of  the  in- 
fluence of  the  hydriatic  procedures  upon  tissue  change, 
the  fact  that  among  2,400  patients  treated  at  his  in- 
stitute, 56  per  cent,  gained  in  flesh,  30  per  cent,  lost 
weight,  and  14  per  cent,  remained  unchanged. 

This  is  especially  demonstrable  in  the  improve- 
ment of  the  appetite  and  increase  of  flesh  in  cases 
previously  very  much  depreciated  by  loss  of  blood 
owing  to  diseased  condition  of  digestive  organs,  in 
phthisis  and   carcinoma  even,   and   in   many  persons 


_  56  - 

whose  age  (over  fifty)  would  render  the  weight  some- 
what stable.  Those  hydriatic  procedures  which 
stimulate  diaphoresis  are  especially  calculated  to  aid 
tissue  metamorphosis  and  changes  in  the  blood.  Pro- 
fuse perspiration  involves  losses  of  water  and  salts. 
Inasmuch  as  there  is  a  constant  effort  of  the  system 
to  maintain  the  integrity  and  constancy  of  the  blood, 
the  removal  of  these  salts  by  any  means  involves  a 
compensatory  effort  on  the  part  of  the  tissues  and 
organs,  which  must  impress  certain  changes  upon 
them. 

From  these  briefly  stated  experimental  deduc- 
tions and  facts  it  would  seem  that  more  or  less  intense 
impressions  are  made  upon  tissue  metamorphosis  by 
different  degrees  of  cold  and  heat,  that  the  latter  may 
be  adapted  with  more  or  less  precision  to  the  effect 
aimed  at.  How  these  changes  may  be  made  more  to 
the  benefit  of  the  patient  will  be  shown  in  the  clinical 
portion  of  the  work.  Suffice  it  to  state  here  that  even 
the  composition  of  the  blood  has  definitely  changed 
by  various  hydriatic  procedures.  These  changes  are 
not  only  evidenced  by  the  improved  ruddiness  of  the 
previously  anaemic  patient,  but  they  have  been  de- 
termined by  the  haemometer  of  Fleishl  and  Hayem. 

INFLUENCE     OF     THERMIC      APPLICATIONS      UPON      THE 
BODV    TEMPERATURE. 

Without  entering  upon  the  physiology  of  heat- 
production  and  elimination,  many  of  whose  points  are 


—  57  — 
still  sub  Judice,  we  propose  to  show  clearly  how  the 
temperature  of  the  human  body  may  most  surely  be 
modified  by  thermic  influence  from  without.  This 
must  suffice  for  our  purposes,  inasmuch  as  it  is  the 
•aim  of  this  work  to  demonstrate  only  by  accepted 
facts  the  potent  influence  of  hydriatic  measures,  which 
are  but  the  conveyors  of  thermic  impressions  upon 
the  human  economy. 

One  physiological  fact  stands  undisputed  above 
all  others,  viz.,  that  the  temperature  of  a  living  part 
or  organ  depends  upon  the  amount  of  arterial  blood 
circulating  within  its  tissue.  The  fact  that  venous 
blood  returning  from  an  organ  in  a  high  state  of  func- 
tional activity  is  warmer  than  the  arterial  blood  pass- 
ing into  it,  is  alone  sufficient  evidence  of  the  proposi- 
tion that  the  arterial  circulation  is  an  important  ele- 
ment in  the  equalization  of  the  body  temperature, 
aside  from  heat  production.  Add  the  physiological 
fact  that  all  tissue  change,  all  organic  action,  depends 
upon  vascular  activity,  by  means  of  which  excretory 
and  secretory  elements  are  carried  to  and  from  it,  and 
that  the  accumulated  heat  in  the  organs  is  equalized 
by  the  great  streams  of  blood  which  constantly  pass 
through  them,  and  we  have  a  combination  of  elements 
which  almost  controls  temperature  variations. 

We  have  shown  in  a  preceding  chapter  how 
hydriatic  procedures  influence  the  circulation.  It  re- 
mains now  to  demonstrate  how,  by  utiUzing  this  pow- 
erful influence,  we  may  reduce  or  elevate  the  temper- 


_  58  - 

ature  in  the  human  economy.  That  the  application 
of  baths  of  various  kinds  is  potent  in  this  direction, 
has  been  recognized  since  the  primitive  days  of  medi- 
cal investigation.  Indeed,  the  idea  that  the  reduction 
of  temperature  is  the  chief,  if  not  the  sole,  attribute 
of  the  baths  has  so  strongly  rooted  itself  in  the  pro- 
fessional mind  that  it  is  difficult  to  dislodge  it  to-day, 
when  we  have  come  to  realize  that  this  is  only  one  of 
its  valuable  manifestations. 

There  is  no  evidence  to  prove  that  the  influence 
exerted  by  external  thermal  agents  is  traceable  to  the 
heat-producing  centres.  There  is  abundant  evidence, 
however,  to  prove  that  this  influence  is  directly  ex- 
erted upon  that  most  important  heat-regulating  ele- 
ment, the  peripheral  cutaneous  circulation.  The  mode 
of  action  in  this  direction  is  twofold.  It  is  a  well 
known  fact  in  physical  science  that  two  bodies  of  dif- 
ferent temperatures,  by  coming  in  contact,  will  at 
once  make  an  effort  to  equalize  their  respective  tem- 
peratures. This  law  applies  to  inanimate  bodies, 
however,  and  is  only  applicable  to  the  living  body  up 
to  a  certain  point,  because  the  latter  is  endowed  with 
compensatory  powers  which  enable  it  to  resist  danger- 
ous encroachments  from  external  temperature  agencies. 

COMPENSATORY    ACTION. 

The  utilization  of  these  very  compensatory  powers 
enables  us,  as  will  be  shown,  to  influence  the  temper- 
ature of  the  body  powerfully  in  health  and  disease — 
more  powerfully  in  the  latter  than  in  the  former. 


~  59  — 
The  temperature  of  any  portion  of  the  body  sur- 
face may  be  reduced  or  elevated  by  its  contact  with 
media  of  different  temperatures,  until  death  of  the 
part  by  freezing  or  scalding  occurs.  But  so  soon  as 
this  occurs,  the  inner  parts  are  protected  against 
further  destructive  invasion  by  the  intervention  of  the 
dead  part.  On  the  other  hand,  temperature  whose 
effect  falls  short  of  destroying  the  parts  in  contact 
with  it  cannot  be  conveyed  to  the  deeper  parts  to  any 
extent,  because  the  collateral  circulation  is  enhanced 
in  the  muscular  structure,  endowing  the  parts  invaded 
with  more  vitality;  because  the  muscular  tissue  is  a 
bad  conductor;  and  because  the  tonic  contractions  of 
the  muscle  which  ensue  upon  the  application  of  cold, 
for  instance,  create  more  heat.  Thus  the  external 
parts  are  well  defended  against  the  invasion  of  ther- 
mic agencies  by  direct  action,  and  our  means  of  re- 
ducing or  elevating  the  temperature  of  the  body  by  this 
means  are  very  meagre. 

FALLACIES    EXPOSED. 

The  sooner  this  important  point  is  thoroughly 
mastered  by  the  profession,  the  better.  For  the  fal- 
lacious idea  that  cold  baths,  for  instance,  reduce  tem- 
perature by  the  direct  effect  of  the  cold  is  still  so 
firmly  fixed  in  the  minds  of  many  that  it  is  regarded 
as  axiomatic.  The  fact  is  that  the  colder  the  bath  the 
less  intense  its  power  of  reducing  internal  temperature. 
The  mouth  temperature  being  so  commonly  accepted 


—  6o  — 

as  correct  is  the  cause  of  this  fact  not  being  appre- 
ciated. I  have  often  seen  the  mouth  temperature, 
after  a  bath  of  65^,  in  typhoid  fever,  reduced  to 
normal,  when  the  rectal  temperature  was  two  degrees 
higher,  although  both  were  carefully  taken  for  five 
minutes,  or  even  longer  in  the  mouth. 

This  point  has  never  been  published,  but,  being 
a  clinical  fact,  I  must  insist  upon  it  here,  as  I  shall 
elsewhere  also,  in  order  that  the  unreasoning  prejudice 
against  the  cold  bath,  which  has  its  origin  in  the  idea 
that  its  antithermic  effect  is  in  proportion  to  the  low 
temperature  of  the  bath,  may  be  removed.  The  fact 
is,  as  shown  by  Liqbermeister  (Handbuch  der  Path- 
ologie  und  Therapie  des  Fiebers,  page  102),  that,  dur- 
ing the  action  of  extraordinary  heat  abstraction  from 
the  external  surface,  if  its  intensity  does  not  exceed 
certain  limits,  the  inner  temperature  of  the  body 
does  not  fall,  but  even  rises  a  little. 

The  second  and  most  important  temperature 
effect  of  thermic  agencies,  externally  applied,  lies  in 
the  immense  power  the  latter  gives  over  the  cutaneous 
circulation.  We  know  from  the  investigations  of  sev- 
eral physiologists  that,  when  a  portion  of  the  skin  is 
moderately  heated,  the  temperature  of  neighboring 
portions  is  cooled,  and  that,  when  cutaneous  surfaces 
are  moderately  cooled,  the  neighboring  structures  pre- 
sent a  proportionally  higher  temperature.  This  effect 
is  traceable  to  the  collateral  anaemia  produced  by 
withdrawal  of  blood  to  the  surface  to  which  warmth 


—  6i   — 

is  applied,  and  by  the  driving  of  blood  from  the  sur- 
face to  the  inner  structure  when  cold  is  applied. 

REACTION    AIMED    AT. 

Reaction  follows  both  of  these  conditions,  either 
restoring  the  equilibrium  or  disturbing  it  in  an  opposite 
direction.  Fleury,  who  has  done  so  much  in  France 
toward  explaining  hydriatic  procedures  upon  physio- 
logical principles,  offers  the  following  results  deduced 
from  careful  experiment:  Dipping  the  body  into  mod- 
erately cool  water  (48°  to  58°  F.)  for  thirty  minutes 
reduced  the  temperature  of  the  surface,  while  the 
inner  temperature  did  not  change  at  all.  The  more 
brief  the  application,  the  colder  it  was  made,  and  the 
higher  the  surrounding  temperature,  the  more  rapid 
and  complete  is  the  reaction.  The  reaction  entailing 
the  re-establishment,  and  even  the  increase,  of  the  pre- 
vious temperature  depends  upon  the  conduct  of  the 
patient  after  the  applications,  it  being  more  rapid  and 
complete  under  active  and  passive  exercise  of  the 
parts,  especially  a  warmer  surrounding  medium. 

Another  important  deduction  made  by  Fleury  is 
the  fact  that  reaction  depends  upon  the  individuality 
of  the  patient  and  conditions  of  the  circulation  and 
innervation  at  the  time.  These  simple  facts  have 
again  and  again  been  verified  by  numerous  authentic 
authorities,  and  may,  if  properly  grasped,  lead  to  a 
correct  understanding  of  many  seeming  paradoxes  in 
hydrotherapy. 


—    62    — 

WINTERNITZ'S     LAW. 

They  confirm  the  law  long  ago  enunciated  by 
Winternitz,  that  the  amount  of  temperature  reduction 
depends  more  upon  the  intensity  of  the  thermic  irri- 
tation of  the  cutaneous  sensory  nerves  than  upon  any 
other  element. 

The  commonly  observed  fact  that  a  drunken  man 
may  have  his  toes  frost-bitten,  while  one  in  a  less  de- 
pressed condition  of  the  nervous  system  may  present 
a  ruddy,  healthful  glow  from  the  same  exposure,  is 
but  an  illustration  of  the  last  of  Fleury's  laws. 

PRACTICAL    DEDUCTIONS. 

In  typhoid  and  other  infectious  fevers  it  is  ^'mport- 
ant  to  bear  this  law  in  mind,  for  the  same  bath  which 
may  stimulate  and  refresh  a  patient  in  the  first  w.eek 
may  in  the  third,  when  his  nervous  system  is  depreciat- 
ed by  disease,  prove  a  fatal  depressant.  For  the  same 
reason  patients  treated  from  the  beginning  with  cold 
baths  have  their  nervous  systems  and  all  functions  de- 
pending on  them  so  perfectly  sustained  that  they  can 
bear  baths  later  in  the  disease  which  in  neglected  cases 
it  would  be  homicidal  to  apply.  Disregard  of  these 
patent  facts  is  the  reason  why  hydrotherapy  has  failed 
so  frequently  in  the  hands  of  otherwise  well-informed 
men.  It  requires  special  study,  to  further  which  this 
work  is  written;  but  it  is  so  plain  that  by  grasping  its 
well  known  principles  it  may  be  made  quite  clear. 

The   chief   elements,  then,  in   the    influence    we 


-63- 

may  exercise  upon  heat  regulation  is  derived,  so  far 
as  we  can  determine  it  positively,  from  our  power  to 
regulate  the  temperature  of  the  surface  of  the  body. 
This  is  accomplished  by  the  change  in  the  general 
•circulation  which,  as  referred  to  above,  follows 
thermic  applications  to  the  periphery. 

If,  during  the  abstraction  of  heat  from  the  sur- 
face, friction  is  resorted  to,  the  effect  upon  tempera- 
reduction  is  more  intense.  This  will  be  exemplified 
further  in  the  "  Rationale  of  the  Cold  Bath  in  Fever." 

SUMMARY. 

Winternitz  sums  up  the  automatically  acting 
agencies  which  protect  the  body  against  serious  heat 
abstraction,  aside  from  the  simultaneous  changes  in 
heat  production,  as  follows:  "Sinking  of  the  body 
temperature  by  the  physical  law  of  contact;  elevation 
of  temperature  in  the  muscular  structure  enveloping 
the  entire  body;  the  constancy  of  temperature  of  the 
inner  organs  as  induced  by  the  reactions  which  are 
signs  of  a  changed  blood  flow  and  heat  distribution, 
and  the  acceleration  of  the  circulation,  which  may  be 
accepted  as  a  manifestation  of  rising  temperature. 
The  automatically  acting  protective  agencies  against 
injurious  rise  of  body  temperature  are,  aside  from 
the  change  in  heat  production:  Increase  of  heat 
from  both  the  skin  and  lungs  due  to  the  enlarged 
blood  stream  flowing  through  them;  increase  of 
cutaneous   secretion,  due   to    reflex    excitation,  made 


-  64  - 

possible  by  increased  flow  of  blood  through  the  skin; 
and  change  in  the  distribution  of  the  blood.  The 
importance  of  all  these  processes  for  the  maintenance 
of  a  constant  temperatnre  is  a  priori  obvious.  When- 
ever an  energetic  contraction  of  the  muscles  and 
vessels  of  the  skin  drives  this  blood  within,  the  giving 
off  of  heat  from  the  surface  must  be  diminished. 
There  is  less  blood  circulating  in  the  skin,  the  circula- 
tion being  the  chief  medium  of  heat  equalization 
between  the  exterior  and  interior  of  the  body.  There 
is  less  heat  given  off  at  the  periphery,  and  less  blood 
cooled  off  there.  The  loss  of  heat  is  diminished  in 
proportion  to  the  diminution  of  the  difference  of 
temperature  between  the  surface  of  the  body  and  the 
medium  in  contact  with  it  and  the  diminished  area  of 
the  warmth-giving  blood  stream.  The  cooling  of  the 
body  takes  place,  aside  from  the  loss  of  heat  in  respi- 
ration, ingesta,  and  excreta,  only  in  proportion  to  the 
direct  heat  conduction  through  the  single  tissue 
layers,  each  of  which  presents  a  different  resistance  to 
conduction.  Hence,  by  contraction  of  the  muscular 
vessels  of  the  skin  and  the  forcing  out  of  better  con- 
ducting fluid  from  the  cutaneous  and  subcutaneous 
tissues,  the  heat  loss  from  the  periphery  is  diminished 
and  the  heat  conduction  through  the  tissues  impeded. 
Cooling  (almost  to  complete  stoppage  of  the  circula- 
tion) is  diminished  somewhat  in  the  manner  in  which 
it  may  be  done  in  a  cooling-coil  apparatus  when  the 
stream  is  interrupted  in  it." 


-  65  - 

Opposite  conditions  ensue  in  case  the  skin  is  irri- 
tated by  heat,  when  its  vessels  dilate  and  more  blood 
is  forced  through  it.  The  surface  temperature  is 
raised,  the  difference  between  it  and  the  surrounding 
medium  is  enlarged,  and  the  heat  dissipation  is  in- 
creased. It  is  to  the  credit  of  Winternitz  to  have 
first  demonstrated  by  actual  mathematical  calcu- 
lations the  correctness  of  these  propositions.  His 
assistant,  Pospischl,  has,  by  actual  demonstration  in 
fifty  observations,  established  the  following  proposi- 
tions : 

1.  Driving  of  the  blood  from  and  stoppage  of 
the  circulation  in  a  part  diminishes  the  loss  of  heat 
up  to  70.6  per  cent. 

2.  The  interruption  of  the  circulation  by  the 
production  of  passive  hyperaemia  diminishes  loss  of 
heat  up  to  46.2  per  cent. 

3.  Mechanical  irritants  may  produce  an  increase 
of  heat  loss  up  to  95  per  cent. 

4.  Weaker  chemical  irritants  produce  an  increase 
of  heat  loss  to  40  per  cent.;  intense  irritants,  on  the 
contrary,  only  to  8  per  cent. 

5.  Thermic  influences  which  produce  cutis  an- 
serina  diminish  heat  loss  up  to  44.5  per  cent. 

6.  A  warm  rain-bath  may  by  this  means  induce 
a  reduction  of  heat  loss  up  to  38.7  per  cent. 

7.  Partial  cold,  wet  rubbing  may  increase  heat 
loss  up  to  80  per  cent. 

8.  Cold  rain-baths,  with  subsequent  rest,  produce, 

5    EEE 


—  66  — 

after  a  transitory  diminution  of  temperature,  an  in- 
crease of  23  per  cent, 

9.  Cold  rain-baths,  with  subsequent  exercise, 
increase  heat  loss  up  to  66.6  per  cent. 

10.  Warm  rain-baths,  with  cold  fanning  and 
subsequent  rest,  increase  heat  loss  16  per  cent. 

11.  In  two  cases  of  fever  the  heat  loss  during 
the  rising  of  the  temperature  was  diminished  25.4  per 
cent. 

If  we  accept  as  the  result  of  these  exact  investi- 
gations the  deduction  that  the  heat  dissipation  may 
be  decreased  70  per  cent.,  or  increased  90  per  cent., 
thus  enabling  us  to  induce  compensatory  fluctuations 
that  may  be  three  times  the  normal,  we  have  a  ready 
explanation  why  these  compensatory  agencies  serve 
to  maintain  the  constancy  of  the  body  heat.  We 
must  also  accept  the  deduction  that  in  this  manner 
may  be  explained  the  rise  of  temperature  in  fevers 
and  its  reduction  by  hydriatic  procedures,  as  will  be 
shown  further  on. 

VALUABLE    AID    OF     MECHANICAL     ACTION     UPON     THE 
SKIN    DURING    BATH. 

The  utilization  of  this  flexible  cutaneous  agency 
for  heat  maintenance  enables  us  in  disease  powerfully 
to  influence  temperature.  To  Winternitz  belongs  the 
credit  of  having  first  demonstrated  how  active 
mechanical  action  on  the  skin,  combined  with  the  ap- 
plication of  cold  water,  enhances  the  temperature-re- 


-  67  - 

ducing  effect.  He  has  shown  that  by  friction,  or 
other  active  stimulation  of  the  surface  circulation 
during  the  bath,  as  by  the  wet  sheet,  half  bath,  etc., 
the  cutaneous  vessels  may  be  made  to  dilate  quickly 
and  in  tonic  action,  so  that  a  larger  area  for  cooling 
off  the  blood  which  circulates  in  near  proximity  to  the 
cooling  medium,  the  water,  is  created.  The  cooler 
blood,  passing  inward,  is  exchanged  for  hot  blood 
coming  from  within.  A  simple,  yet  effective  method 
of  reducing  the  temperature  is  now  created,  which 
explains  many  inconsistencies.  It  is  now  clear  that 
the  amount  of  compensatory  heat  increase  is  not  de- 
pendent upon  the  absolute  amount  of  heat  abstrac- 
tion, but  upon  the  intensity  of  the  thermic  nerve 
irritation,  and  the  degree  of  actual  cooling  of  the 
peripheral  terminal  nerve  fibres,  which  govern  by  re- 
flex action  the  increase  of  heat  production.  This  will 
also  explain  why  two  baths  of  the  same  temperature 
and  duration  may  produce  quite  different  effects  in 
the  same  individual,  if  in  the  one  case  he  lies  quiet 
and  undisturbed,  and  in  the  other  he  is  subjected  to 
active  friction  of  the  periphery.  In  the  first  instance 
the  peripheral  circulation  is  impeded,  the  surface  is 
cooled  down  almost  to  the  temperature  of  the  sur- 
rounding water,  the  heat  production  in  the  muscular 
layers  is  greatly  enhanced,  and  the  rectal  temperature 
not  much  diminished;  in  the  other,  peripheral  circula- 
tion is  stimulated,  the  cutaneous  surface  is  cooled 
down  less,  but  the  blood  coming  to  its  related  vessels 


^  6S  — 

is  cooled  more,  the  heat  production  in  the  muscles  is 
diminished,  especially  as  tremor  is  prevented,  and^ 
therefore,  the  rectum  temperature  is  lowered. 

Winternitz  is  convinced  of  the  correctness  of  this 
view,  which  he  has  long  advocated  and  defended 
against  influential  opposition,  inasmuch  as  recent  ex- 
periments by  others  have  verified  it.  The  exact  inves- 
tigations of  Speck  on  the  influence  of  cooling  upon 
the  respiratory  process  (D.  Archiv.  fiir  Klin.  Med., 
xxxiii)  demonstrate  that  heat  abstraction  from  the 
surface  of  the  body  produces  an  increase  of  CO 2  ex- 
halation and  oxygen  imbibition  only  when  voluntary 
or  involuntary  muscular  action  is  not  avoided.  Loewy 
(quoted  by  Winternitz)  has  shown  from  exact  observa- 
tions, in  Zunz  laboratory,  upon  the  influence  of  cool- 
ing upon  the  exchange  of  gases  in  the  human  body 
(Pfliiger  Archiv.,  xlvi),  that  the  actually  positive  fact 
in  the  regulation  of  the  body  temperature  in  man  is 
that  the  first  result  of  cold  as  an  irritant  induces  con- 
traction of  the  skin  and  its  vessels,  which  produces  an 
impediment  to  heat-dissipation.  The  latter  is  com- 
pensated completely  in  mild  heat-abstraction,  but  less 
completely  when  the  latter  is  more  intense.  After 
the  latter  the  temperature  will  sink  more  or  less;  in 
the  former  it  will  remain  constant. 

Changes  in  heat-production  may  be  added  to  by 
tonic  or  clonic  muscular  contraction,  either  voluntary 
or  involuntary,  which  may  occur  after  cold  or  after 
other  irritants.     Their  importance  as  heat-regulating 


-69  - 

elements  stands  in  man  far  below  that  of  the  skin; 
they  cannot  prevent  a  fall  of  temperature.  Hence  it 
may  be  regarded  as  a  law  that  the  regulation  of  the 
body  temperature  depends  chiefly  upon  the  changes 
in  heat-dissipation,  therefore  chiefly  upon  the  condi- 
tion of  the  peripheral  nerves  and  vessels.  Inasmuch 
as  we  may  influence  the  latter  energetically  by  hydri- 
atic  procedures,  as  we  have  shown  above,  we  possess 
a  powerful  agent  for  affecting  the  temperature  of  the 
body  in  health  and  disease.  Winternitz  points  with 
justifiable  pride  to  this  confirmation,  by  the  most  re- 
cent investigations,  of  the  view  he  has  long  promul- 
gated, and  he  concludes  his  magnificent  chapter  on 
this  subject  as  follows: 

"  If  you  connect  the  above  with  what  happens  in 
thermic  and  mechanical  procedures,  with  regard  to 
the  blood  and  heat  distribution,  the  control  of  heat 
dissipation — or  rather,  as  I  may  say  now,  the  control 
of  the  degree  of  heat  production — you  will  find  it 
quite  natural  that  hydrotherapy  is  the  most  sovereign 
remedy,  not  only  in  the  first  stages  of  febrile  diseases, 
not  only  in  fevers  depending  upon  heat  retention,  but 
in  all  fever  processes  especially,  because  no  other 
remedy,  if  properly  applied,  is  capable  of  meeting  the 
chief  therapeutic  indications  of  the  latter." 

That  we  are  fully  in  accord  with  Winternitz  on 
this  point  we  shall  endeaver  to  demonstrate  in  the 
chapter  on  the  hydriatic  treatment  of  fevers. 

We  have  now,  as  briefly  as  the  importance  of  the 


—  70  — 

subject  would  admit,  dilated  upon  the  rationale  of 
the  action  of  water,  as  a  vehicle  of  thermic  agencies, 
upon  those  functions  of  the  body  upon  which  its  in- 
tegrity  depends  in  health  and  disease.  An  agent  of 
such  power  must  be  capable  of  utilization  in  thera- 
peutics as  no  other  known  agent  can  be  shown  to  be. 


CHAPTER  III. 

TECHNIQUE    AND    CLINICAL    APPLICATION    OF 
HYDROTHERAPY. 

Much  of  the  prejudice  existing  against  hydro- 
therapy is  due  to  the  more  or  less  complex  methods 
adopted  and  insisted  upon  by  certain  advocates  of 
this  treatment.  It  is  the  aim  of  this  work  to  simplify 
hydriatic  procedures  by  modifications  which  the 
author  has  found  of  value  in  his  general  practice 
(private  and  hospital),  and  to  divest  it  of  mysticism 
and  empiricism. 

NECESSITY  OF  PRECISION. 

The  first  element  of  success  in  all  hydriatic  pro- 
cedures is  precision  in  executing  them,  with  regard  to 
method,  duration,  temperature,  etc.  The  absolute 
necessity  of  an  exact  technique  in  the  application  of 
water  as  a  remedial  measure  is  unfortunately  not  ap- 
preciated by  the  profession,  and  its  neglect  is  un- 
doubtedly a  cause  of  the  failures  which  have  operated 
in  preventing  the  more  general  adoption  of  hydro- 
therapeutics  by  the  practitioner.  Water  is  so  simple, 
so  readily  obtainable,  and  so  easily  applied  that  it 
would  seem  an  unnecessary  refinement  of  therapeutics 
to  enlarge  upon  the  methods  of  its  application.  On 
the  other  hand,  too,  the  empirical  hydropaths  and 
water-cure  doctors  have  divided  and  subdivided  their 


—  72  — 

procedures  into  numerous  baths  and  douches,  etc., 
each  one  infallibly  adapted  to  certain  conditions.  It 
shall  be  our  aim  to  steer  between  the  Scylla  of  in- 
difference and  the  Charybdis  of  over-activity,  to 
simplify  these  methods,  and  to  instruct  the  general 
practitioner  in  such  hydriatic  procedures  as  his  com- 
mon sense  will  enable  him  to  apply  under  the  guid- 
ance of  physiological  and  pathological  principles. 

The  first  step  in  this  direction  is  the  appreciation 
of  the  fact  that,  while  there  is  no  sleight-of-hand  or 
mystery  in  the  hydrotherapeutic  methods,  there  does 
exist  a  necessity  for  absolute  precision  in  the  applica- 
tion of  water,  simple  and  universally  applicable 
though  it  be.  A  few  illustrations  from  our  clinical 
experience  will  impress  this  lesson  more  forcibly  than 
the  simple  statement. 

ILLUSTRATIONS. 

Some  time  ago  one  of  the  house  physicians  of 
one  of  our  metropolitan  hospitals  informed  the  writer 
that  the  cold  bath  treatment  of  typhoid  fever  had 
been  inaugurated  in  his  institution.  Inquiry  regard- 
ing the  method  adopted  elicited  the  fact  that  the 
patient  was  wrapped  in  a  wet  sheet,  and  ice  water 
was  poured  from  a  carriage  sponge  over  the  entire 
surface  of  the  sheet,  until  the  temperature  was  decid- 
edly reduced  and  a  reduction  of  5°  had  been  noted. 
The  prognosis  made  by  the  writer,  that  the  woman 
would  die  under  this    unphysiological    management, 


—  73  — 
was  verified  in  two  days.  Failure  in  this  case  is  attrib- 
utable to  the  fact  that  refrigeration  was  the  chief  aim 
of  the  treatment.  The  success  of  the  hydriatic  man- 
agement of  typhoid  fever  rests,  as  will  be  shown,  upon 
the  principle  that  the  refreshing  influence  of  cold 
water  upon  innervation  is  the  important  indication. 
The  latter  is  fulfilled  by  promoting  reaction  during 
the  bath  by  friction  of  the  entire  body.  This  point 
has  been  fully  elucidated  in  the  section  on  the 
Rationale  of  the  Action  of  Water.  That  the  neces- 
sity for  precision  is  well  understood,  however,  by 
some  of  our  metropolitan  hospital  physicians  was 
made  evident  to  the  .writer  by  the  receipt  of  a  written 
request  from  Dr.  Austin  Flint,  one  of  the  attendants 
at  Bellevue  Hospital,  to  aid  him  in  instructing  his 
house  staff  of  two  divisions,  which  will  doubtless  ere 
long  bear  fruit  in  the  saving  of  life  and  in  comfort. 

Another  illustration  may  be  of  service.  The 
writer  had  occasion  to  suggest  intestinal  irrigation  in 
two  cases  of  summer  diarrhoea  of  infants.  Finding 
the  treatment  painful  and  inefficient  in  these  cases, 
inquiry  elicited  the  fact  that  in  one  case  the  attend- 
ant (who  is  an  accomplished  physician)  had  cut  off 
the  lower  third  of  a  Nelaton  catheter,  and  converted 
the  upper  into  a  drainage  tube  by  cutting  three  eye- 
holes into  it.  Is  it  surprising  that  the  introduction  of 
such  a  tube  was  painful  and  irrigation  through  it 
ineffective  ?  One  thorough  irrigation  in  accordance 
with   the    technique   laid    down    under  this   heading 


—  74  — 
changed  the  entire  aspect  of  the  case.  In  the  other 
case  referred  to,  the  attendant  had  used  a  No.  4 
French  rubber  catheter,  had  placed  the  child  in  the 
dorsal  position,  and  attempted  to  irrigate  with  a 
Davidson  syringe.  The  tube  doubled  up  in  the  rec- 
tum, its  upper  end  was  too  small  to  connect  with  the 
syringe  point,  and  failure  was  the  inevitable  result  of 
this  neglect  of  proper  technique.  The  reverse  of  this 
picture  is  contained  in  the  following  extract  from  a 
letter  received  by  the  writer.  Dr.  Chas.  Schram, 
New  York  City,  says: 

"  I  have  successfully  managed  a  desperate  case 
of  summer  diarrhoea  in  a  child,  18  months  old,  by 
following  out  implicitly  the  principles  of  treatment 
laid  down  by  you  in  your  monograph  on  the  subject 
published  a  year  ago  (Medical  News,  July  7th,  1888). 
The  case  was  one  of  a  severe  type,  with  high  fever, 
muco-purulent  and  bloody  dejections,  and  vomiting. 
I  feel  that  I  owe  you  a  debt  of  gratitude  for  the 
assistance  derived  from  studying  and  following  the 
principles  laid  down  in  your  paper." 

A  few  days  ago  a  masseur  applied  to  the  writer 
for  work,  stating  that  he  was  quite  familiar  with 
hydriatic  procedures.  Being  asked  to  describe  the 
dripping  sheet  process,  he  said  that  a  sheet  should  be 
dipped  into  cold  water  and  thrown  over  the  patient, 
who  should  rub  himself  with  it  as  well  as  he  could,  with 
the  aid  of  the  attendant.  This  specialist  had  entirely 
lost  sight  of  the  important  elements  of  the  technique^ 


—  75  — 
which  are  the  use  of  a  linen  sheet,  a  thermometer  for 
exactly  estimating  the  temperature,  and  the  necessity 
for  the  patient  remaining  entirely  passive  while  the 
attendant  applies  the  friction  outside  of  the  sheet. 
Recently  a  letter  from  one  of  the  most  justly  eminent 
neurologists  of  America  was  shown  to  the  writer,  in 
which  the  following  directions  were  given:  "Wrap 
yourself  in  a  cold  wet  sheet  every  night,  and  have 
some  one  to  rub  you  down."  This  would  be  equiva- 
lent to  saying  to  a  patient:  "Take  some  quinine  once 
a  day."  Precision  in  the  temperature  of  water  (which, 
if  cold,  may  vary  from  35  to  80°)  is  as  important  as 
is  dosage  of  medicinal  agents. 

The  technique  of  hydrotherapy  may  be  studied 
under  (i)  Procedures  having  for  their  object  distinctly 
local  effects;  (2)  Procedures  having  for  their  object 
general  effects. 

PROCEDURES    FOR    LOCAL    EFFECTS. 

The  mechanical  influence  of  water  as  a  remedial 
measure  is  well  illustrated  in  its  simplest  form  when 
administered  as  lukewarm  water  for  the  purpose  of 
acting  as  an  emetic  in  gastric  disturbances  or  as  an 
enema  in  constipation.  Here  we  have  the  simple 
mechanical  effect  acting  by  over-distension.  For  the 
former  purpose  the  object  may  be  accomplished  best 
by  abundant  quantities  of  water  at  a  temperature  of 
about  90°  F.  A  higher  or  lower  temperature  would 
probably  fail.     As  an  enema,  experience  has  shown 


-  76  - 

that  water  at  any  temperature  from  60°  to  95°  may  be 
used,  a  sufficient  quantity  to  produce  mechanical  dis- 
tension being  the  chief  requisite.  Even  in  these  sim- 
ple procedures  due  attention  to  detail  will  alone  bring 
success.  A  small  quantity  will  fail  as  an  enema,  while 
a  temperature  above  95°  or  below  60°  will  probably 
fail  to  produce  emesis,  as  every  tyro  knows. 

THERAPEUTIC     APPLICATION. 

As  a  mechanical  agent  we  obtain  from  water  im- 
portant effects  in  the  treatment  and  diagnosis  of 
gastric  and  intestinal  disturbances.  In  chronic  gas- 
tric catarrh,  for  instance,  there  is  no  remedy  equal 
to  half  a  pint  or  a  pint  of  hot  water,  above  100°  F., 
an  hour  before  each  meal,  as  may  be  indicated  in 
each  case.  This  measure,  which  has  almost  become 
a  popular  craze,  is  now  receiving  more  appreciation 
from  the  profession.  But,  like  other  hydriatic  pro- 
cedures, its  efficacy  depends  upon  attention  to  details. 
The  originator  of  the  method  recommends  the  ad- 
ministration of  a  pint  of  water  as  hot  as  can  be  sipped, 
one  hour  before  each  meal,  the  object  being  to  remove 
mucus  and  fermenting  material  from  the  stomach, 
and  thus  to  enable  it  to  perform  its  function  un- 
hampered. The  correctness  of  the  theory  is  demon- 
strated by  clinical  data.  A  half  pint  of  hot  water 
slowly  and  deliberately  sipped  not  less  than  half  an 
hour  before  one  or  all  meals,  as  the  severity  of  the 
case   may   indicate,  will    be   sufficient,  provided    the 


—  77  — 
stomach  is  occasionally  irrigated  with  luke-warm 
water  five  hours  after  a  meal.  If  the  diagnosis  be 
correct,  there  is  no  medicinal  treatment  or  physio- 
logical aid  by  acid  or  pepsin  which  can  approach  this 
simple  cleansing  of  the  mucous  Iming.  That  the  hot 
water  does  remove  the  mucus  in  mild  cases  I  have 
demonstrated  by  the  experiment  of  washing  the 
stomach  half  an  hour  after  it  was  drunk.  When, 
however,  the  mucous  is  tenacious  or  in  large  quan- 
tity, it  fails.  It  would  seem  unnecessary  to  refer  to 
so  simple  a  matter  as  the  time  for  administering  hot 
water,  but  I  have  observed  failures  due  to  the  neglect 
of  this  point.  A  lady  at  Long  Branch,  who  had  been 
under  the  care  of  an  eminent  hospital  physician, 
sought  my  advice  for  an  obstinate  gastric  catarrh. 
When  hot  water  before  breakfast  was  ordered,  she 
remarked  that  the  treatment  had  proved  inefficacious 
in  her  case  after  trial  of  several  months.  Inquiry 
elicited  the  fact  that  she  had  been  drinking  the  hot 
water  immediately  before  eating.  The  slow  and 
gradual  sipping  of  hot  water  an  hour  before  break- 
fast produced  a  favorable  change,  which,  together 
with  proper  diet,  secured  her  recovery. 

GASTRIC   AND    INTESTINAL  DISTURBANCES  OF  INFANTS. 

The  mechanical  effect  of  irrigation  is  the  most 
valuable  remedial  measure  in  these  affections,  next  to 
the  proper  attention  to  diet.  For  the  removal  of 
the  ingested  and  multiplying  bacteria  from  the  gastro- 


-  78  - 

intestinal  canal  of  an  infant  with  summer  diarrhoea, 
irrigation  by  a  soft  rubber  tube,  as  introduced  by 
Epstein  and  earnestly  advocated  by  Seibert,  offers  a 
valuable  resource  in  obstinate  cases,  even  after  failure 
of  the  most  reliable  remedies.  The  method  of  intro- 
duction is  as  follows:  A  No.  8  Nelaton  or  Jacques 
catheter  is  gently  but  firmly  pushed  through  the 
pharynx  into  the  stomach  of  the  child,  which  is  held 
upright  in  the  nurse's  arms.  In  very  many  infants 
this  is  not  a  difficult  procedure,  as  they  will  aid  it  by 
sucking  the  tube.  In  older  children  it  is  more  diffi- 
cult, and  had  better  be  avoided.  The  procedure 
should  not  be  made  in  the  presence  of  the  mother,  nor 
of  anxious  friends,  if  it  can  be  avoided,  because  the 
occasional  anxious  and  cyanotic  appearance  of  the 
baby,  although  evanescent  and  not  denoting  harm, 
will  interfere  with  the  procedure  in  many  instances. 
The  catheter  being  lodged  in  the  stomach,  it  is  con- 
nected with  a  fountain  syringe,  from  which  simple 
boiled  water  of  a  temperature  of  95°  F.  is  poured. 
The  infant  will  probably  vomit,  but  it  is  better  to  dis- 
connect the  catheter  from  the  syringe  and  allow  the 
water  containing  products  of  fermentation,  mucus, 
and  undigested  curds  to  escape  through  the  tube.  If 
the  tube  is  not  firmly  held  it  will  be  vomited. 

TECHNIQUE     OF    LAVAGE    FOR    DIAGNOSIS    AND    TREAT- 
MENT. 

The  diagnostic  value  of  water  may  be  referred  to 
in  connection  with  this  branch  of  the  subject.     Its 


—  79  — 
value  as  a  diagnostic  and  therapeutic  agent  in  dys- 
pepsia has  so  frequently  come  under  my  observation 
that  I  would  here  briefly  refer  to  it.  There  is  no  dis- 
ease that  perplexes  the  physician  more  than  the  vari- 
ous types  of  dyspepsia.  To  diagnose  an  ordinary 
gastric  catarrh  or  a  neurosis  of  the  stomach  from 
other  forms  of  gastric  trouble  is  not  devoid  of  diffi- 
culty. When  a  case  of  chronic  dyspepsia  presents 
itself,  it  is  my  custom  to  bid  the  patient  eat  a  full 
meal  at  12:30  p.m.  and  present  himself  at  5:30  p.m. 
for  irrigation  of  the  stomach  by  tepid  water.  A  long, 
soft,  but  firm,  rubber  tube,  with  open  end  and  one 
eye  near  the  latter,  is  introduced  into  the  stomach. 
The  necessary  quantity  of  warm  water,  usually  two  to 
six  quarts,  being  in  readiness,  a  basin  is  placed  upon 
a  chair  in  front  of  the  patient.  It  is  well  to  protect 
the  clothing  of  the  latter  by  a  doubled  sheet  or,  what 
I  use  in  my  office,  an  oil-cloth  apron,  secured  around 
the  neck  and  reaching  over  the  knees.  Artificial 
teeth,  if  present,  are  removed.  The  patient  is  re- 
quested to  sit  upright  with  his  head  thrown  back. 
The  physician,  standing  on  his  right,  dips  the  lower 
end  of  the  tube  in  warm  water  (oil  is  unnecessary  and 
injures  the  tube  eventually).  Holding  it  between  the 
thumb  and  forefinger,  he  introduces  it  over  the  tongue, 
until  it  strikes  the  back  of  the  pharynx.  The  patient 
is  now  told  to  bend  his  head  forward.  In  the  first 
effort  gagging  will  ensue,  but  an  abundant  mucus  is 
secreted  in  the  throat  which  lubricates  the  tube.    The 


—  8o  — 

patient  should  be  reassured,  if  he  feels  choked  or  dis- 
tressed, by  informing  him  that  this  is  the  usual  effect 
and  that  if  he  will  keep  his  mouth  well  open  he  can- 
not choke,  because  there  is  ample  room  in  the  pharynx 
for  a  larger  tube.  The  physician  must  refrain  from 
sharing  the  patient's  excitement,  and  by  his  calm  de- 
meanor reassure  him  when  he,  as  is  often  the  case^ 
protests  that  he  is  utterly  unable  to  do  his  bidding. 
I  have  failed  only  twice  in  many  hundreds  of  in- 
stances, and  I  have  observed  that  some  patients,  who 
at  first  declared  it  impossible  to  swallow  the  tube,  be- 
came so  expert  that  they  executed  the  entire  process 
themselves.  Sometimes  an  obstruction  is  met  with  at 
the  cardiac  orifice,  which  contracts  upon  the  tube.  If 
an  assistant  will  pour  warm  water  in  at  this  moment, 
the  spasm  will  relax  and  the  tube  pass  steadily  down. 
At  times  it  is  necessary  to  move  the  introduced  por- 
tion back  and  forth.  This,  however,  should  be 
avoided,  because  it  produces  gagging.  It  will  be 
found  that  each  introduction  is  more  free  from 
trouble  and  distress.  The  tube  being  introduced  as 
far  as  the  mark  usually  found  upon  it  (which,  how- 
ever, may  be  measured  in  each  case  by  laying  the 
tube  along  the  curve  of  the  proposed  course  from  the 
mouth  to  the  xiphoid  cartilage),  the  patient,  or,  better, 
an  assistant,  is  asked  to  hold  it  lightly  but  securely 
near  the  teeth^  the  mouth  being  held  open.  Through 
a  funnel  connected  with  the  upper  end  water  is  now 
poured    into   it.     If  vomiting  ensues,   the   patient  is 


—  8i   — 

quietly  asked  to  lean  over  the  basin  and  allow  the 
vomit  to  flow  out  around  the  tube.  If  the  irrigation 
is  done  too  early  after  a  meal,  or  if  undigested  food  or 
large  quantities  of  tenacious  mucus  obstruct  the  fen- 
estrum  and  lower  opening,  the  water  should  be  poured 
from  a  height  by  holding  the  funnel  up.  Sometimes 
it  may  become  necessary  to  remove  the  tube,  clean  it, 
and  re-introduce  it.  This  embarrasses  the  process 
greatly,  if  it  is  the  initial  effort.  Hence  it  is  advisable 
to.  make  the  first  irrigation  six  or  seven  hours  after 
luncheon,  or  before  breakfast.  The  water  being 
slowly  poured  into  the  funnel,  whose  lower  end  is 
firmly  grasped  by  the  physician's  left  thumb  and  index 
finger,  flows  readily  into  the  stomach.  After  about  a 
pint  has  been  entered,  the  funnel,  still  held  firmly,  is 
turned  down  into  the  basin.  This  should  be  done 
quickly,  while  the  water  is  still  flowing^  in  order  to 
establish  siphonage.  A  neglect  of  this  simple  point 
defeats  the  proper  emptying  of  the  stomach.  If  the 
water  does  not  flow  out  readily,  the  tube  may  be  in- 
troduced farther  or  withdrawn  a  little.  During  the 
whole  procedure  the  patient  requires  reassurance.  I 
have  sometimes  succeeded  in  inducing  timid  patients 
to  make  the  attempt,  after  a  failure,  by  allowing  them 
to  witness  the  introduction  in  a  well-drilled  case. 
This  is  rarely  necessary,  however — patience,  calm- 
ness, reassurance,  gentleness,  and  skill  in  manipula- 
tion and  overcoming  obstacles  will  surely  succeed  in 
nearly  every  case. 

6  EEE 


—    82    — 

I  have  been  somewhat  minute  in  describing  the 
technique,  because  experience  convinces  me  of  the 
value  of  details.  The  stomach  should  be  thoroughly 
washed,  even  if  several  gallons  of  water  be  required, 
but  no  larger  quantity  than  one  pint  should  be  intro- 
duced at  once.  The  washings  are  now  carefully  in- 
spected, when  it  will  be  readily  discovered  if  portions 
of  food  have  remained  undigested.  Thus  a  perfect 
clue  is  afforded  the  physician  to  the  actual  digestive 
powers  of  the  patient,  and  the  latter  obtains  a  valu- 
able guide.  If  the  washings  contain  mucus,  it  is  im-' 
portant  to  distinguish  between  stomach  and  throat 
mucus.  The  former  is  a  thick,  tenacious,  brown  mass 
which  floats  upon  the  surface  of  the  water,  like  the 
scum  on  the  surface  of  a  pond;  the  throat  mucus  is 
thin,  transparent,  stringy,  and  may  be  more  abun- 
dant, being  the  result  of  irritation  by  the  tube  of  the 
pharynx  and  oesophagus.  The  quantity  and  quality 
of  the  stomach  mucus  indicate  with  some  accuracy  the 
condition  of  the  gastric  mucous  membrane.  Its  rapid 
or  slow  disappearance  under  renewed  irrigations  and 
treatment  indicates  the  character  of  the  disease  affect- 
ing the  mucous  lining.  Three  cases  recently  treated 
in  this  manner  may  serve  as  illustrations  of  the  diag- 
nostic and  therapeutic  significance  of  warm  water  ir- 
rigations in  stomach  troubles. 

J.  M.,  a  young  college  student,  complained  last 
winter  of  severe  pain  in  the  epigastric  region,  with- 
out  other   symptoms   of   dyspepsia.     Various    forms 


-83  - 

of  diet,  amounting  at  times  almost  to  starvation, 
afforded  no  relief.  Bismuth  and  magnesia,  hydro- 
chloric acid,  hot  water  before  meals,  and  other  reme- 
dies only  afforded  temporary  relief  in  the  course 
of  several  months.  A  sojourn  in  the  country  com- 
pletely restored  him.  On  his  return  he  appren- 
ticed himself  to  a  microscope  manufacturer.  This 
occupation  being  sedentary  and  his  mid-day  meal 
taken  hastily  at  a  restaurant,  the  old  trouble  very 
soon  developed.  The  pain  now  became  so  severe 
that  he  often  refrained  from  eating  to  avoid  it.  He 
was  constipated  and  suffered  from  eructations.  A 
full  meal,  consisting  of  soup,  fish,  meat,  and  vege- 
tables, was  ordered  at  12:30,  and  his  stomach  was 
washed  out  five  hours  later.  A  small  quantity  of 
bread,  some  celery,  and  spinach  appeared  undigested, 
the  remainder  of  his  food  being  disposed  of .  Pain  was 
almost  unbearable  until  the  stomach  was  cleaned,  when 
it  ceased  at  once.  The  entire  surface  of  the  water  in 
the  basin  was  covered  with  a  thick,  brown  mucus. 
The  diagnosis  of  chronic  gastric  catarrh,  due  to  pro- 
longed nervous  dyspepsia,  was  made,  and  the  follow- 
ing simple  treatment  was  adopted:  He  was  ordered 
an  aloes  and  mastic  pill  every  night,  a  meat  pulp  diet, 
irrigations  of  the  stomach  every  second  day,  and 
pulv.  magnesia  for  pain.  The  stomach  was  washed 
nine  times,  the  interval  being  prolonged  as  the  course 
of  treatment  progressed.  The  pain  returned  but  once, 
the  patient  remaining  entirely  free  from  it  until  he  re- 


-  84  - 

sumed  his  college  studies.  He  was  ordered  hot  water 
before  breakfast,  and  gradual  return  to  ordinary  diet. 
In  this  case  the  same  care  in  diet  had  been  ineffectual 
until  the  cleansing  of  the  stomach  prepared  the  way 
for  the  more  successful  dietetic  and  hygienic  manage- 
ment. 

When  the  case  is  not  of  long  duration  nor  of  sec- 
ondary origin,  and  the  patient  is  young,  complete 
recovery  may  be  almost  invariably  obtained  by  this 
simple  diagnostic  aid.  In  the  more  chronic  cases 
other  management,  to  be  presently  detailed,  is  indi- 
cated. Another  case  in  which  the  diagnosis  by  irri- 
gation rendered  treatment  successful  may  be  of  value: 

Miss  M.,  an  anaemic  young  lady,  presented  every 
symptom  of  gastric  catarrh,  with  the  addition  of  occa- 
sional vomiting  of  mucus  and  food,  and  severe  pain  in 
the  epigastric  region.  She  had  been  treated  several 
months  without  success,  but  was  immediately  relieved 
by  an  exclusive  diet  of  hot  milk  and  seltzer  water, 
gradually  increased  to  chopped  meat  diet,  preceded 
by  hot  water.  A  cautious  return  to  a  more  varied 
diet  brought  a  return  of  pain,  with  increased  vio- 
lence; eructations  of  gas  were  explosive,  and  her  con- 
dition was  precarious.  Five  hours  after  a  test  meal, 
her  stomach  was  irrigated,  and  it  was  discovered  she 
had  digested  her  food  well.  A  small  quantity  of 
tenacious  stomach  mucus  floated  out,  portions  of 
which  were  so  deeply  tinged  with  blood  that  they 
appeared   like   pieces   of    beef   pulp.     Diagnosis    of 


-85  - 

ulcus  ventriculi  was  now  clear.  Stomach  irrigation 
was  therefore  refrained  from.  The  usual  treatment 
by  rest  in  bed,  systematic  nutrition  by  milk,  sarco- 
peptones,  and  farinaceous  food,  with  alkalies,  com- 
pletely changed  the  aspect  of  the  case  in  a  few  days. 
It  was  continued  two  months,  and  now  the  patient  is 
in  perfect  health,  eating  a  mixed  diet,  and  gaining  flesh 
rapidly.  There  had  never  been  the  slightest  evidence 
of  blood  in  her  ejecta,  and  she  had  been  treated  by 
several  physicians,  including  myself,  for  gastric 
•catarrh,  until  irrigations  made  the  diagnosis  clear. 

Dr.  H.  asked  me  (March  4th,  1890),  after  read- 
ing the  account  of  the  above  cases  I  had  given  in  a 
paper  before  the  New  York  County  Medical  Society, 
to  wash  his  stomach  for  diagnosis.  Patient  looked 
haggard;  suffered  from  migraine;  had  worked  hard  as 
a  country  practitioner  for  eighteen  years;  vomited  con- 
tinuously, with  headache;  had  tried  everything,  includ- 
ing rest  for  eight  months;  dieted  carefully;  no  serious 
gastric  distress  after  eating.  An  eminent  authority 
had  diagnosed  gastric  catarrh,  and  had  put  him  on 
meat  diet.  He  had  had  section  of  external  rectus  of 
both  eyes;  thought  to  be  astigmatic;  sleeps  well. 
Dr.  Carl  Koller  found  no  error  of  refraction.  My 
diagnosis  of  nervous  dyspepsia  was  confirmed  by  the 
-entire  absence  of  mucus  and  complete  digestion  of  all 
food  taken  five  hours  previously,  which  surprised  the 
patient  greatly.  A  mixed  diet  was  ordered,  which,  to- 
•gether  with  hydrotherapy  externally  applied,  relieved 
him  greatly. 


—  86  — 

It  might  be  claimed  that  these  cases  might  have 
been  diagnosed  without  the  aid  of  stomach  irrigation. 
But  I  cannot  over-estimate  the  assistance  which  these 
ocular  demonstrations  constantly  afford  me.  More- 
over, the  moral  effect  upon  a  hypochondriacal  patient, 
who  sees  the  mucus  gradually  diminishing,  is  not  an 
insignificant  factor  in  the  treatment  of  some  of  these 
trying  cases. 

GASTRIC    IRRIGATION    IN    TREATMENT. 

In  the  management  of  long-standing  gastric  ca- 
tarrh, the  most  unpromising  cases  that  come  under  my 
care,  the  diagnosis  may  be  at  once  established,  but  the 
treatment  by  irrigation  is  not  so  successful  as  in  those 
of  recent  origin. .  As  an  addition  to  hygienic  and 
dietetic  management,  the  latter  is  useful,  however, 
inasmuch  as  it  frees  the  stomach  thoroughly  from 
accumulations  of  fermenting  material  and  tenacious- 
mucus,  and  prevents  the  over-distension  by  gases, 
which  paralyzes  the  motor  functions  of  the  gastric 
walls,  and  forms  an  almost  insurmountable  obstacle  ta 
recovery. 

Much  discussion  has  been  caused  by  the  time  at 
which  these  irrigations  are  most  useful.  Riegel  and 
others  insist  that  at  bedtime  this  lavage  is  most  use- 
ful, because  it  enables  the  stomach  to  be  restored  to 
a  nearly  normal  condition,  free  from  fermenting 
material  and  particles  of  undigested  matter,  during 
the   night.     There   is  doubtless  good  reason  for  his 


-  87  - 

preference,  but  in  those  parts  of  this  country,  especi- 
ally in  cities,  where  the  evening  meal  is  usually  about 
three  and  a-half  or  four  hours  before  retiring,  much 
good  nutritive  material  is  lost  by  the  practice;  hence, 
as  a  rule,  it  is  desirable  to  resort  to  irrigation  in  the 
morning,  except  in  cases  which  are  under  constant 
supervision,  in  which  the  interval  between  the  last 
meal  and  the  irrigation  may  be  made  longer,  and  the 
meal  of  less  substantial  food.  Hence  the  time  must 
depend  a  good  deal  upon  the  individual  case.  When, 
for  instance,  we  have  a  case  characterized  by  accumu- 
lation of  large  quantities  of  tenacious  mucus,  which 
interferes  with  digestion  and  demands  large  quanti- 
ties of  water,  I  am  in  the  habit  of  washing  the  stom- 
ach before  dinner,  directing  the  patient  to  take  his 
luncheon  of  some  light  broth  or  hot  milk  at  noon. 
Five  hours  suffice  for  their  digestion;  if  they  have  not 
been  disposed  of  in  six,  it  is  probable  that  they  will 
be  propelled  into  the  bowel  undigested,  and  will, 
therefore,  be  lost  to  nutrition.  Hence  a  luncheon  at 
12  and  lavage  at  6  is  most  suitable  in  business-men 
and  women.  I  have  recently  had  a  busy  lawyer  under 
my  care,  in  whom  the  products  of  decomposition  pro- 
duced an  offensive  odor  in  the  washings,  mingled,  as 
they  were,  with  such  enormous  quantities  of  mucus 
that  six  to  eight  quarts  of  water  were  required  for 
complete  cleansing.  ^  He  vomited,  prior  to  treatment, 
every  other  day  for  months,  and  then,  being  partly 
free  from  the  accumulations,  manaa^ed  to  attend  to 


his  business.  There  was  not  a  particle  of  hydro- 
chloric acid  in  his  stomach,  according  to  frequent 
analyses.  The  motor  power  was  so  far  in  abeyance 
that  articles  of  food  were  recognized  in  the  washings 
twenty-four  hours  after  he  had  partaken  of  them. 
This  case  was  completely  relieved  of  his  symptoms,  re- 
quiring now  only  bi-weekly  washings.  It  proved  to 
be  a  case  of  stricture  of  malignant  character,  to  which 
the  patient  finally  succumbed.  Lavage  served  to 
make  life  tolerable  and  to  prolong  it. 

When  the  motor  function  of  the  stomach  is  im- 
paired without  other  organic  involvements,  as  in 
anaemia  or  other  conditions  which  depreciate  the  gen- 
eral muscular  and  nerve  tone,  lavage  should  not  be 
resorted  to  habitually.  A  weekly  or  bi-weekly  evacu- 
ation suffices  for  diagnostic,  prognostic,  and  therapeu- 
tic purposes,  while  other  appropriate  treatment  is 
resorted  to  for  the  restoration  of  the  general  condi- 
tion. 

LAVAGE  COMBINED  WITH  EXTERNAL  HYDROTHERAPY. 

Miss  W.,  daughter  of  an  Ohio  physician,  aet.  23, 
anaemic,  applied  for  treatment  May  15th,  1889.  She 
had  been  ill  three  years;  at  first  suffered  fainting  fits 
at  menstrual  period;  afterwards  violent  pains  in  right 
hand,  traversing  body  and  concentrating  in  epigas- 
trium, for  which  her  father  administered  morphia  for 
a  month.  Her  stomach  then  became  irritable,  and 
has  continued  so  until  the  present  time;  she'vomited 


-  89  - 

and  spat  up  nearly  all  her  food,  more  frequently 
solids.  Sea-baths  did  not  improve  her.  She  studied 
hard,  and  got  worse.  In  the  fall  of  1888  she  lived  on 
milk  and  farinaceous  mush,  and  her  stomach  was 
washed  out  regularly,  but  she  grew  worse.  She  now 
became  emaciated,  took  peptonized  milk  for  a  month, 
but  vomited  it;  tried  meat  with  same  effect.  Last 
fall  she  lived  on  grapes,  which  agreed  with  her.  Had 
tonics,  pepsin,  and  all  possible  medication  her  father 
and  brother  could  muster,  without  avail.  She  was 
^ent  to  me  by  Dr.  Francke  Bosworth,  after  being  in 
the  city  for  three  weeks  without  improvement.  She 
now  vomits  every  day,  is  anaemic  and  depressed.  She 
traces  her  ailment  to  painting-lessons,  but  I  drew 
from  her  a  history  of  a  potent  psychical  factor  as  a 
■cause  in  the  sudden  violent  insanity  of  the  favored 
nurse  of  her  childhood. 

Diagnosis:  Gastric  neurasthenia  of  the  pure 
type.  Stomach  was  washed  twice  a  week  to  remove 
mucus  and  fermenting  material.  General  faradiza- 
tion daily,  also  the  wet  sheet.  She  received  a  brisk 
rubbing  over  the  snugly  applied  dripping  sheet  (water 
at  60°  F.),  while  she  stood  in  a  tub  of  warm  water. 
Under  this  general  treatment  vomiting  ceased  en- 
tirely. She  went  to  the  seaside  improved  in  July,  and 
on  her  homeward  journey  called  to  tell  me  that  she 
had  grown  stout  and  felt  perfectly  well.  A  year  later 
she  writes:  "You  would  not  recognize  me  as  the 
same  girl  whom  you  treated." 


—  90  — 

When  retention  of  undigested  matter  and  pro- 
duction of  decomposition  are  due  to  pathological  dila- 
tation, and  thus  impair  the  motor  functions,  lavage 
may  be  practiced  with  advantage  as  often  as  is  neces- 
sary to  cleanse  the  stomach.  It  will  be  useful  as  an 
adjunct  as  well  as  a  curative  agent.  Life  may  be  pro- 
longed, in  malignant  cases  especially,  by  this  simple 
hydriatic  procedure. 

DILATATION    OF    THE  STOMACH. 

Kussmaul  held  long  ago,  and  his  view  has  been 
found  correct  by  myself  and  many  other  observers, 
that  the  stomach  tube,  by  completely  emptying  the 
stomach,  may  restore  the  contractile  capacity  of  the 
stomach  walls,  if  they  have  not  been  entirely  ex- 
hausted, just  as  the  catheter  does  in  ischuria  occasion- 
ally. 

In  all  cases  of  this  kind,  due  to  actual  stricture 
or  simply  to  gastric  catarrh,  with  excessive  fermenta- 
tion, aided  by  mucus,  which  encourages  the  forma- 
tion of  butyric  acid,  gastric  irrigation  a  long  time 
after  meals,  either  before  dinner  or  breakfast,  is  per- 
haps the  most  valuable  therapeutic  resource  we  have, 
if  cautiously  introduced.  In  nervous  dyspepsia  it  is 
advisable  not  to  be  urged  to  too  frequent  irrigation 
by  the  alleged  gastric  fulness  of  which  the  patients 
complain.  An  occasional  irrigation  cleanses  the 
stomach  of  possible,  though  rare,  accumulations,  and 
exerts  a  psychical  effect  which  is  of  some  value.     The 


—  91   — 

products  of  fermentation  require  occasional  removal. 
The  use  of  small  quantities  of  ice-water  by  lavage 
acts  as  a  douche  upon  the  stomach  walls,  and  aids 
other  means,  such  as  electricity,  etc.,  in  restoring  its 
tone. 

GASTRALGIA. 

In  this  painful  malady,  even  when  not  dependent 
upon  accumulated  fermented  material  (which,  by  the 
way,  IS  its  most  frequent  source),  the  irrigation  with 
hot  water  acts  as  would  a  poultice  to  an  external 
sensitive  part.  A  striking  case  is  reported  from 
Kussmaul's  Clinic.  A  woman,  22  years  of  age, 
teacher,  suffered  after  three  years  of  dyspepsia  from 
agonizing  gastralgia,  which  failed  to  yield  to  all 
remedies,  including  electricity,  wet  compresses, 
blisters,  etc.,  and  yielded  only  to  morphia.  Becoming 
habituated  to  the  latter,  she  gave  up  work,  and  en- 
tered the  clinic  in  a  miserable  condition,  feeble, 
emaciated,  dirty  pale;  abdominal  wall  covered  by 
cicatrical  knots  from  hypodermatics,  etc.  Diet,  rest, 
etc.,  were  unavailing;  morphine  was  still  required. 
Her  stomach  was  now  irrigated  with  warm  water 
every  morning,  while  empty.  The  water  returned 
almost  clear  and  a  little  acid.  This  was  continued 
with  advantage  to  pain  and  renewal  of  appetite.  Car- 
bonized water,  mixed  with  plain  water  at  100°,  was 
now  substituted,  2-3  litres  being  used.  In  three 
weeks  she  could  eat  beefsteak,  etc.,  and  take  a  walk. 
Warm  baths  at  night,  of   10  minutes'  duration,  were 


—  92  — 

now  administered  with  great  benefit.  The  morphine 
injection  gradually  became  less  necessary.  To  aid  in 
obtaining  spontaneous  actions  of  the  bowels  faradiza- 
tion was  produced  by  introducing  a  wire  electrode 
through  the  tube  into  the  half  filled  stomach,  and 
placing  another  electrode  upon  the  outside  for  five 
minutes.  In  four  weeks  she  was  entirely  restored. 
In  cases  in  which  the  soothing  effect  of  warm  irriga- 
tion is  desired,  it  is  self-evident  that  the  warm  water 
should  be  allowed  to  remain  in  the  stomach  for  several 
minutes,  and  repetition  resorted  to. 

INTESTINAL    OBSTRUCTIONS. 

Another  valuable  application  of  water,  discov- 
ered by  Kussmaul  in  1882  and  published  in  1884,  is 
the  treatment  of  Ileus  by  irrigation  of  the  stom- 
ach with  a  large  volume  of  warm  water.  We  cer- 
tainly encounter  no  class  of  cases  which  afford  us 
more  anxiety.  Hitherto  their  non-surgical  treatment 
consisted  of  purgatives,  enemata  of  water  or  air,  the 
injection  of  large  quantities  of  crude  mercury,  and, 
lastly,  opiates — remedies  to  which  many  cases,  even 
those  that  are  not  due  to  actual  stenosis,  fail  to  yield. 
Hence  we  welcome  any  addition  to  our  measures 
with  due  appreciation.  The  first  case  treated  by 
Kussmaul  was  admitted  into  his  hospital  in  March, 
1882,  having  been  unsuccessfully  treated  by  all  the 
usual  methods  for  eight  days.  The  stomach  was 
thoroughly  washed   out,  feculent  masses  were    evac- 


—  93  — 
uated,  and  the  irrigation  was  repeated  every  three  or 
four  hours  until  the  water  came  away  clear.  Patient 
fell  asleep  for  the  first  time,  and  on  awakening  passed 
a  thin,  yellow  stool.  No  further  treatment  was  neces- 
sary; recovery  was  complete  in  five  weeks. 

A  second  case  occurred  a  year  later.  Here, 
again,  all  remedies  had  been  exhausted  for  nine  days 
without  result.  Laparotomy  was  determined  upon, 
but  Professor  Liicke,  the  surgeon,  requested  Kuss- 
maul  to  see  the  patient  before  operating.  One  large 
irrigation  of  the  stomach  removed  immense  masses  of 
feculent  matter,  and  was  followed  by  sleep,  which  had 
been  denied  the  patient  even  under  large  doses  of 
morphine.  Other  cases  have  been  reported  by  Sen- 
ator and  others,  in  some  of  which  stomach  irrigation 
acted  as  a  curative,  in  others  as  a  very  comforting 
palliative  agent,  when  surgical  interference  became 
necessary,  the  distressing  vomiting  and  great  disten- 
sion being  removed.  We  have  in  this  hydriatic  pro- 
cedure a  valuable  means,  which  should  never  be 
neglected,  ere  laparotomy  is  decided  upon,  and  after 
its  failure  we  may  more  promptly  decide  upon  lapar- 
otomy than  hitherto. 

In  a  case  occurring  in  my  own  service  at  the 
Manhattan  Hospital,  stercoraceous  vomiting  and  the 
terrific  urgent  straining  accompanying  or  succeeding 
it  in  a  case  of  stenosis  were  so  completely  allayed  as  to 
lull  the  house  staff  into  a  false  sense  of  security,  from 
which  the  collapsed  condition  of  the  patient  aroused 


—  94  — 

them.  Laparotomy  by  Dr.  Wilkie  revealed  one  intus- 
susception and  one  constriction  by  bands.  The  value 
of  the  hot  water  irrigation  as  an  anti-emetic  is  here 
illustrated  in  an  extreme  case. 

COLIC    FROM    GALLSTONES. 

In  the  discussion  of  Senator's  paper,  Rosenthal 
referred  to  the  fact  that  in  two  cases  of  colic  from 
gallstones  irrigation  of  the  stomach  not  alone  relieved 
the  pain  and  vomiting,  but  the  gallstones  were  seen  in 
the  faeces.  Although  I  have  failed  to  obtain  any  such 
result  from  this  treatment,  its  simplicity  commends  it 
for  repetition  in  other  cases. 

It  is  well  to  remember  the  statements  here  repro- 
duced by  such  men  as  Kussmaul,  Senator,  and  Rosen- 
thal, when  we  are  face  to  face  with  these  distressing 
cases. 

INTESTINAL     IRRIGATION — TECHNIQUE     IN     INFANTILE 
DIARRHCEA. 

This  is  a  remedy  in  the  diarrhoea  and  dysentery 
of  infants  which  affords  more  comfort  to  the  doctor 
and  security  to  the  patient  than  the  whole  materia 
medica.  I  say  this  advisedly  after  an  experience  of 
thirty-one  years  in  a  large  general  practice  in  a  country 
and  city  clientele.  But  it  must  be  borne  in  mind  that 
irrigation  cannot  be  accomplished  by  an  enema  of 
warm  water,  this  would  act  as  an  irritant  and  create 
additional  disturbance.  A  rubber  horse  catheter  or  a 
Nelaton  catheter  should  be  used  for  this  purpose,  be- 


—  95  — 
cause  its  walls  are  firm  and  yet  elastic,  and  its  length 
admits  of  its  deep  introduction.  It  should  be  attached 
to  a  fountain  syringe,  containing  one  quart  of  water 
that  has  been  boiled  for  half  an  hour,  and  in  which 
half  a  drachm  of  chloride  of  sodium  has  been  dis- 
solved. The  infant  is  placed  upon  the  abdomen  in 
the  lap  of  the  attendant.  The  tube,  anointed  with 
vaseline  and  firmly  held  between  the  thumb  and  index 
finger  of  the  right  hand,  is  gently  introduced  into  the 
anus.  The  pressure  of  the  fingers  is  now  somewhat 
relaxed,  in  order  that  the  water  may  flow,  while  the 
tube  is  being  gently  but  firmly  pushed  into  the  in- 
testinal canal.  Whenever  it  meets  an  obstruction  it 
should  be  withdrawn  a  little  and  gently  persuaded  to 
pass  upward.  If  the  water  is  allowed  to  flow  and  dis- 
tend the  bowel,  introduction  is  greatly  facilitated. 
Remembrance  of  this  point  has  frequently  saved  me 
the  mortification  of  abandoning  the  introduction. 
Sometimes  it  is  more  readily  introduced  when  discon- 
nected from  the  syringe.  When  the  upper  point  has 
reached  the  transverse  colon,  or  cannot  be  introduced 
farther,  it  is  held  quietly  until  about  a  quart  of  water 
has  been  passed.  There  will  be  no  distension,  be- 
cause the  pressure  of  the  child's  body  upon  the  nurse's 
lap  will  aid  in  expelling  the  water  as  rapidly  as  it  is 
introduced.  If  it  does  not  return  it  may  be  allowed 
to  run  out  through  the  catheter.  I  have  sometimes 
in  extreme  cases  added  with  advantage  one-half 
grain  bichloride  of  mercury  to  the  quart  of  water, 


-  96  - 

allowing  always  an  extra  pint  of  plain  water  to  follow 
the  medicated  injection  to  prevent  poisoning. 

Experience  has  convinced  me  that  thorough 
irrigation  of  the  large  intestine,  administered  by  the 
physician  or  by  a  competent  nurse,  under  special  in- 
struction, every  four  or  five  hours,  lessens  the  number 
and  changes  the  character  of  the  movements,  and 
produces  a  most  soothing  effect  upon  the  patient.  I 
have  frequently  seen  infants- who  had  been  tossing  in 
pain,  purging  and  vomiting,  drop  into  gentle  slumber 
while  the  water  was  still  flowing.  Almost  invariably 
a  quiet  slumber  follows  the  irrigation,  the  purging 
ceases  or  is  much  modified,  and  the  whole  aspect  of 
the  case  is  changed.  The  result  of  irrigation  is  the 
removal  of  bacteria,  mucus,  undigested  food,  and 
fermenting  material. 

RATIONALE    OF    ACTION. 

J.  L.  Smith  has  found  the  lesions  in  summer  diar- 
rhoea ''in  all  but  one  of  the  cases  in  the  colon;  in 
thirty-nine,  nearly  or  quite  through  its  entire  extent; 
in  fourteen  it  was  confined  to  the  descending  colon. 
The  portion  of  colon  most  frequently  inflamed  is  just 
above  the  sigmoid  flexure." 

"The  large  intestine,  the  caecum,  sigmoid  flexure, 
and  upper  part  of  the  rectum  were  the  positions  in 
which  the  most  advanced  lesions  were  met  with.  In 
the  small  intestine  the  changes  were  generally  limited 
to  the  lower  part  of  the  ileum,"  says  Holt  in  the  Med- 


—  97  — 
ical  News  of  June  9,  1888.  Hence  we  may  safely 
assume  that  the  irrigations  reach  most  of  the  diseased 
surface,  and  thus  we  follow  the  indications  of  modern 
therapeutics,  to  treat  local  troubles  by  local  measures,  as 
far  as  possible.  The  inflamed  parts  are  not  only 
soothed  by  these  warm  irrigations,  but  the  materies 
morbi,  which  maintain  the  disease,  are  removed  and 
neutralized. 

An  incidental  advantage,  too,  is  the  stimulation 
of  the  hepatic  function  which  this  imitation  of  Krull's 
injections  produces.  While  I  have,  in  severe  cases  of 
dysentery,  resorted  to  the  addition  of  bi-chloride  of 
mercury  with  advantage,  I  regard  the  addition  of 
antiseptics  to  the  irrigating  fluid  as  inadvisable,  in- 
asmuch as  the  solutions  cannot  be  made  sufficiently 
concentrated  to  effect  the  destruction  of  germs  and 
spores  without  endangering  the  integrity  of  the 
mucous  membrane,  or  menacing  the  system  by  poi- 
soning from  absorption.  Further  investigations  may 
develop  a  perfected  medicinal  irrigation.  For  in- 
stance, Cantani's  method  of  tannin  irrigations  in 
cholera  may  be  here  imitated.  He  has  succeeded  in 
reaching  the  stomach  with  these  irrigations.  In 
chronic  and  subacute  cases  these  may  be  valuable  by 
their  local  astringent  action. 

CATARRHAL    JAUNDICE. 

About  ten  years  ago  Dr.  Krull,  a  German  physi- 
cian, treated   eleven   cases  of  catarrhal  jaundice  by 

7  EEE 


-  98- 

simple  cold  water  irrigations  of  the  intestines.  After 
failure  with  other  treatments,  which  almost  invariably 
had  included  the  Carlsbad  waters,  these  irrigations 
succeeded,  first,  in  relieving  the  constipation  and, 
later,  in  re-establishing  the  hepatic  norm.  Dr. 
Lowenthal  reports  (Berl.  Klin.  Wochenschrift,  1886) 
forty-one  cases  of  catarrhal  jaundice,  in  which  all 
but  one  demonstrated  good  and  rapid  effects  from 
intestinal  (anal)  irrigations.  Four  irrigations  of  one 
to  two  quarts  of  a  temperature  varying  from  54°  to 
64°  F.,  increasing  three  degrees  daily  (one  quart 
sufficing  for  children),  were  needed  on  an  average  for 
each  case.  In  all  cases  faecal  evacuations  followed 
the  irrigations,  sometimes  diarrhoea;  these  ceased  if 
the  succeeding  irrigation  was  of  a  somewhat  higher 
temperature.  Grey  or  colorless  clay-like  masses  were 
evacuated  after  the  first  treatment;  after  the  third 
the  faeces  became  slightly  yellowish,  and  after  the 
fourth,  usually  brown.  Gastric  pains  and  oppression, 
headache,  etc.,  ceased,  appetite  returned;  icteric  hue 
disappeared  once  after  the  first,  twice  after  the  sec- 
ond irrigation.  Pruritus,  among  seven  cases,  disap- 
peared after  from  the  second  to  the  fourth  treatment. 
The  skin  began  to  clear  up,  but  continued  dark  for  a 
long  time.  There  were  27  male  and  14  female  pa- 
tients; in  most  of  them  the  cause  lay  in  disturbances 
of  the  digestion;  two  claimed  sudden  fright  as  causes. 
Other  reports  of  similar  results  are  found  in  recent 
literature,  confirming  the  value  of  this  hydriatic  7neas- 


—  99  — 
ure,  so  that  it  may  be  regarded  as  established.  I  can 
testify  from  personal  experience  to  its  beneficial  effect 
in  catarrhal  jaundice,  and  to  its  failure  in  jaundice 
from  gallstones.  Once  in  24  hours  I  place  the  patient 
in  the  knee-elbow  position,  and  pour  from  one  to  two 
quarts  of  water  of  54°  to  60°  F.  into  the  rectum  from 
a  fountain  syringe.  The  patient  is  induced  to  retain 
the  fluid  as  long  as  possible.  On  the  following  day 
the  temperature  of  the  water  is  increased  two  degrees, 
and  this  increase  is  continued  until  yo'^  F.  is  reached. 
From  two  to  six  irrigations  are  sufficient  to  produce 
the  desired  result.  In  my  own  experience  the  gastric 
and  hepatic  pains  ceased  after  the  first  injections, 
appetite  soon  returned,  and  jaundice  disappeared 
more  or  less  rapidly,  but  I  failed  in  subduing  the 
pruritus  by  this  measure. 

DYSENTERY. 

In  acute  dysentery  of  infants,  as  well  as  of  adults, 
irrigation  with  water,  about  95°,  made  thoroughly 
aseptic  by  long  boiling,  has  proved  in  the  hands  of 
the  best  clinical  observers  a  valuable  auxiliary  by  re- 
moving pathological  products,  subduing  hypersemia, 
relieving  tenesmus,  and  thus  enabling  the  inflamed 
bowel  to  obtain  that  rest  which  in  all  inflammatory 
affections  is  the  chief  element  of  restoration.  All 
these  effects  are  due  to  the  mechanical  cleansing 
action  of  water.  They  demand  careful  attention  to 
the  details  of  the  procedure,   which,   though  simple, 


experience  has  taught  me  are  necessary  to  be  incul- 
cated. How  not  to  do  it  is  illustrated  by  the  case 
cited  in  the  opening  of  this  chapter. 

Clinical  evidence  of  the  value  of  this  simple 
hydriatic  measure  is  readily  obtained.  The  most  re- 
cent report  on  the  subject  I  find  in  the  Medical  Age, 
Aug.  25th,  189 1.  Dr.  Peter  S.  Korytin  (Russia)  de- 
tails fifteen  successive  cases  of  diphtheritic  (9)  and 
catarrhal  (6)  dysentery  which  he  treated  daily  with 
warm  (30°  R.  or  100°  F.)  large  enemata  of  six  pints- 
either  of  filtered  water  from  the  tap  or  of  a  carbolic 
solution,  10  to  20  grains  to  the  6  pints  of  distilled 
water,  which  is  practically  equivalent  to  plain  water.. 
Only  one  of  the  patients  died,  the  remaining  fourteen 
making  excellent  recoveries.  The  total  number  of 
the  injections  in  individual  cases  varied  from  one  to 
six,  averaging  two  and  a  half.  The  injected  fluid 
was  retained  by  the  patient  generally  from  five  to  ten 
minutes,  being  sometimes  expelled  in  one  or  two,  and 
in  other  cases  in  from  fifteen  to  twenty,  minutes. 
The  following  effects  were  commonly  observed:  Ab- 
normal distension  and  pain  speedily  subsided;  the 
frequency  of  stools  diminished  and  tenesmus  de- 
creased; the  spirits,  appetite,  and  sleep  quickly  im- 
proved; the  stools  soon  became  painless,  more  solid, 
and  free  from  offensive  odor,  mucus,  blood,  sloughs, 
and  shreds,  while  the  temperature  became  normal. 
No  therapeutical  difference  whatever  was  noticed  be- 
tween   carbolic    and   simple   enemata.       It   appears, 


lOI     

therefore,  that  the  beneficial  results  of  the  treatment 
should  be  attributed  simply  to  the  thorough  washing 
out  of  the  large  intestine.  (See  Dr.  Hiram  Corson's 
views,  page  i6.) 

LEAD     COLIC. 

Reisland  published  in  the  Berliner  Klin.  Wochen- 
schrift,  1875,  an  obstinate  case  of  this  disease  in  a 
potter.  He  had  been  constipated  for  five  days,  despite 
the  most  active  purgation;  he  was  collapsed,  with  fre- 
quent spasms  of  the  arms  and  legs  and  vomiting  of 
bile;  face  pale  and  ashen.  The  teeth  presented  a 
plain  lead  line;  abdomen,  hard  and  retracted;  pulse, 
small  (65);  temperature,  normal.  Croton  oil  and 
'Opiates  were  ineffectual,  also  enemata.  Four  and  a 
half  litres  of  warm  water  were  now  poured  into  the 
bowel  with  a  Hegar's  irrigator.  The  water  returned 
in  five  minutes,  colored  by  faeces  and  containing  some 
scybala.  He  obtained  so  much  relief  that  the  patient 
insisted  upon  a  repetition.  Three  litres  were  intro- 
duced, and  were  followed  in  half  an  hour  by  the  same 
quantity,  each  injection  being  followed  by  faeces  and 
relief  from  pain.  The  knee-elbow  position  was  prac- 
ticed during  irrigation.  The  patient  became  more 
nauseated,  but  after  the  third  irrigation  he  slept  well 
for  the  first  time  in  six  days.  The  pain  returned,  and 
three  more  injections  of  three  and  two  and  one-half 
litres  brought  stools  and  relief.  On  the  following 
day  the  pain  and  spasms  returned,  and  were  again  re- 
lieved by  irrigation.    He  received  one  more  irrigation 


I02     

of  three  litres,  which  brought  a  good  faecal  evacua- 
tion, and  he  was  assisted  to  entire  recovery  by  a  dose 
of  01.  Ricmi  and  01.  Crotoni  and  a  warm  bath.  In 
Kussmaul's  Clinic  at  Freiburg  this  treatment  has 
been  used  for  many  years.  Whether  lead  colic  be  a 
neurosis  of  the  intestinal  muscular  coat,  or,  as  Riegel 
deduces  from  the  effect  of  amyl  and  pilocarpine,  a 
spasm  of  the  mesenteric  vessels,  it  is  certain  that 
abundant  warm  injections  per  anum  may  avert  a  colic 
in  its  incipiency,  and  act  as  a  good  palliative.  It  is 
very  interesting  to  note  that  this  procedure  quickly 
produces  faecal  evacuations,  irrespective  of  the  rejected 
enemata,  proving  that  they  induce  a  normal  activity 
of  the  intestine.  The  experiments  of  Horvath,  wha 
sent  streams  of  water  through  portions  of  the  intes- 
tines of  living  animals,  demonstrate  that  the  passage 
of  water  (66°  to  105°  progressively)  through  the  in- 
testines excites  peristalsis  (Malbrane,  Berl.  Klin.  W., 
1878). 

WATER    IN    GYN/ECOLOGY. 

Another  illustration  of  the  distinctly  local  effects 
of  water  is  the  application  of  hot  water  in  some  dis- 
eases of  the  female  pelvic  organs.  Those  who  in 
former  years  ordered  injections  of  cold  water,  in 
which  tannin,  sulphate  of  zinc,  alum,  or  other  astrin- 
gents had  been  dissolved,  for  checking  leucorrhoea, 
for  healing  so-called  ulceration,  and  so  forth,  are  in  a 
position  to  appreciate  the  immense  advance  which 
the  .introduction  of  hot  vaginal  douches  has  inaugur- 


—  I03  — 

ated.  If  Dr.  T.  A.  Emmet  had  done  nothing  more 
for  gynaecology,  our  debt  of  gratitude  would  be  great 
indeed.  But  here,  as  in  all  other  applications  of  water 
as  a  therapeutic  measure,  everything  depends  upon 
details — the  method  and  the  temperature  (iio°  F.). 
He  claims,  moreover,  that  it  is  impossible  for  a 
patient  to  give  these  injections  to  herself  so  as  to 
derive  their  full  benefit.  So  different  is  the  corrugat- 
ing, and  therefore  tonic,  effect  of  these  injections, 
when  administered  according  to  his  rules,  that  Dr. 
Emmet  discovered  by  digital  examination  those 
women  who,  among  a  series  in  the  Woman's  Hospi- 
tal, had  been  given  injections  without  their  guidance. 
"We  resort,"  says  Dr.  Emmet,  "  to  the  prolonged  use 
of  hot  vaginal  injections  to  gradually  bring  about  the 
required  contraction  and  to  tone  the  pelvic  vessels. 
Whenever  inflammation  exists,  there  is  essentially  a 
congestion  of  the  arterial  capillaries,  and  when  it  sub- 
sides there  remains,  among  other  results,  a  condition 
erroneously  termed  chronic  inflammation,  a  condition 
essentially  the  same  as  the  one  just  described,  attend- 
ed with  a  loss  of  tone  in  the  vessels  and  an  obstructed 
circulation;  but  it  is  a  misnomer,  since  it  is  found 
where  no  previous  inflammation  has  existed.  The 
usual  seat  of  the  so-called  inflammation,  and  the  cir- 
cumstances under  which  it  is  generally  found,  have 
already  been  stated,  as  well  as  the  fact  that  what  we 
have  chiefly  to  deal  with  is  the  direct  results  of  a  loss 
of   tone    in    the    venous    circulation    throughout    the 


—   104  — 

pelvis.  The  use  of  hot  water  vaginal  injections  is 
equally  beneficial  in  all  those  conditions  which  con- 
stitute the  various  forms  of  disease  in  the  female 
organs  of  generation,  and  which  are  amenable  to  any 
treatment  other  than  a  surgical  procedure,  and  equal- 
ly so  whether  the  congestion  is  venous  or  arterial. 
This  remedy  is  not  to  be  considered  a  cure-all,  but 
one  of  the  most  valuable  adjuncts,  under  all  circum- 
stances, to  other  means.  Yet,  so  beneficial  is  it,  ex- 
cept in  displacements  of  the  uterus,  that,  I  believe, 
more  can  be  accomplished  in  the  treatment  of  the 
diseases  of  women  by  its  use  and  a  carefully  regu- 
lated plan  of  general  treatment  than  by  all  other 
means  combined.  After  a  vaginal  injection  has  been 
properly  administered  in  accordance  with  the  direc- 
tions given  in  Chapter  V,  the  mucous  membrane  will 
be  found  blanched  in  appearance  and  the  usual  cali- 
bre of  the  canal  lessened,  as  after  the  use  of  a  strong 
astringent  injection.  As  the  patient  lies  on  the  back, 
with  her  hips  elevated,  the  blood  will  be  aided  by 
gravity  in  its  return  to  the  heart,  and  the  veins  will  be 
rapidly  emptied  sufficiently  to  relieve  their  over-dis- 
tension. In  this  position,  also,  the  vagina  will  be 
kept  fully  distended  by  the  weight  of  the  water,  and 
only  the  surplus  amount  can  run  off  into  the  bed-pan 
beneath.  The  hot  water  will  then  be  in  contact  with 
every  portion  of  the  mucous  membrane  under  which 
the  capillaries  lie.  The  vessels  going  to  and  from 
the  cervix  and  body  of  the  uterus  pass  along  the  sul- 


—  I05  — 

€us  on  each  side  of  the  vagina,  and  their  branches 
enclose  the  vagina  in  a  complete  network.  The  ves- 
sels of  the  fundus,  through  the  veins  of  which  the 
blood  flows  to  the  liver  and  back  into  the  general 
circulation,  communicate  freely,  by  an  anastomosis, 
with  the  vessels  distributed  to  the  body  and  cervix 
below. 

If,  then,  we  are  able  to  cause  the  vessels  of  the 
vagina  to  contract,  through  the  stimulus  of  the  hot 
water,  we  can,  directly  or  indirectly,  influence  the 
whole  pelvic  circulation.  It  is  most  important  to  ap- 
preciate the  necessity  for  elevating  the  hips,  by  which 
plan  so  large  a  portion  of  the  venous  blood  becomes 
drawn  off  by  gravitation.  If  the  stimulus  of  the  hot 
water  is  then  applied,  so  as  to  cause  the  vessels  to 
-contract  still  more,  we  shall,  for  a  time  at  least,  have 
the  pelvic  circulation  reduced  almost  to  its  natural 
state.  In  order  to  allow  the  contraction  to  be  as  pro- 
longed as  possible,  I  generally  direct  the  injection  to 
be  given  at  night,  in  bed,  just  as  the  patient  is  ready 
to  retire.  Thus,  by  constantly  causing  the  vessels  to 
-contract,  and  by  resorting  to  every  other  means  of 
lessening  the  supply  of  blood  in  the  pelvis,  we  shall 
succeed  eventually  in  securing  a  proper  vascular 
tone.  No  plan  of  treatment  could  be  more  rational 
or  appeal  more  forcibly  to  sound  judgment.  But, 
unfortunately,  owing  to  a  7ieglect  of  details,  it  is  rare 
that  the  slightest  benefit  is  derived  from  the  use  of 
the  injections,  although  so  many  years  have  elapsed 


—   io6  — 

since  the  profession  has  been  fully  informed  as  to 
their  mode  of  action.  For  fifteen  years  at  least  to 
the  time  of  writing  I  have  been  experimenting  by  dif- 
ferent methods  in  the  use  of  hot  water,  and  have  had 
during  that  time  as  large  a  number  of  cases  as  would 
be  likely  to  be  at  the  service  of  any  practitioner,  and 
I  have  arrived  at  the  conclusion  that  it  is  an  impossi- 
bility for  a  patient  to  properly  give  these  injections 
to  herself  so  as  to  derive  their  full  benefit.  Not  the 
slightest  advantage  is  received  from  them  when  ad- 
ministered with  the  patient  in  the  upright  position, 
or,  as  is  the  usual  method,  while  seated  over  a  bidet; 
for,  given  thus,  the  water  does  not  dilate  the  vagina, 
but  escapes  directly  along  the  nozzle  of  the  syringe. 
I  have  found  that  the  best  mode  of  all  is  to  have  the 
injections  while  the  patient  is  placed  on  her  knees 
and  elbows  or  chest.  In  this  position  we  have  the 
assistance  both  of  gravity  and  of  the  pressure  of  the 
atmosphere  to  empty  the  pelvic  veins,  while  the  water 
is  able  to  act  on  a  much  larger  surface  of  the  vagina 
than  it  is  when  the  patient  is  in  any  other  position. 
But  this  position  is  a  difficult  one  to  assume,  since 
those  who  are  in  the  greatest  need  of  hot  water  have 
not  the  strength  to  remain  in  it  long  enough  to  secure 
the  full  benefit;  considerable  difficulty  is  also  experi- 
enced in  keeping  the  patient  dry.  This  latter,  how- 
ever, can  in  a  measure  be  overcome  by  using  a  funnel- 
shaped  receptacle  with  an  india-rubber  tube  attached 
to  the  smaller  end,  the  two  sides  being  indented  suffi- 


—  107  — 

ciently  to  enable  the  patient  to  retain  it  in  place  by 
keeping  the  thighs  together.  I  have  also  used  an 
inclined  plane  to  elevate  the  hips;  it  should  come  be- 
tween the  legs  and  have  a  hole  large  enough  for  the 
buttock,  so  that  the  water  may  flow  into  a  receptacle 
below.  These  methods,  or  any  other  which  the  inge- 
nuity of  the  physician  may  suggest,  can  be  employed, 
so  long  as  the  action  of  gravity  is  brought  into  play 
and  the  vagina  is  fully  dilated  by  the  water.  But,  for 
the  largest  number  of  cases,  the  position  on  the  back, 
with  the  bed-pan  to  elevate  the  hips,  will  be  found  the 
most  convenient.  Few  women  are  so  situated  as  to 
be  unable  to  get  somebody  to  administer  the  injection 
properly,  and  the  inconvenience  of  soliciting  aid  is  a 
trifling  one  considering  the  benefit  to  be  derived  from 
it.  Experience,  too,  has  shown  that,  unless  details  can 
be  carried  out  fully ^  the  process  only  involves  a  waste 
of  time  and  a  tax  on  the  strength  of  the  patient. 
The  temperature  and  quantity  of  water  are  to  be 
varied  according  to  circumstances.  When  the  early 
stages  of  inflammation  are  under  treatment,  it  is 
necessary  that  the  temperature  should  be  elevated 
rapidly  from  that  of  blood  heat  to  iio°,  or  to  as  high 
a  degree  as  can  be  borne  by  the  patient,  and  that  the 
injection  should  be  often  repeated.  For  ordinary 
use  a  gallon  of  water,  two  or  three  degrees  above 
blood  heat,  is  generally  suflicient,  but  the  temperature 
must  be  maintained  at  the  highest  point  by  the  addi- 
tion of  hot  water  from  time  to  time.     The  hour  of 


—   io8  — 

bed-time  is  generally  the  best  in  which  to  seek  for  the 
beneficial  effects  of  hot  water  upon  the  local  irrita- 
tion; for  a  prolonged  vaginal  injection,  at  a  high  tem- 
perature, will  often,  when  given  by  an  experienced 
hand,  act  with  more  promptness  than  an  anodyne  in 
allaying  the  nervousness  and  sleeplessness  of  a  hys- 
terical woman.  I  have  frequently  known  a  patient, 
after  being  well  rubbed  and  having  received  an  injec- 
tion, to  fall  asleep  before  the  nurse  had  completed  the 
process,  and  to  be  so  overcome  with  drowsiness  as  to 
be  but  little  disturbed  when  the  bed-pan  was  removed. 
''  In  rare  instances,  and  from  a  condition  I  am  un- 
able to  explain,  cases  are  met  with  where  a  sense  of 
weight  and  an  uncomfortable  feeling  are  experienced 
about  the  pelvis  after  an  injection  of  water  at  the 
usual  temperature.  In  some  instances  so  much  dis- 
turbance has  resulted  that  I  have  been  obliged  to 
discontinue  its  use.  But  I  have  long  since  ascertained 
that  the  injection  is  well  borne  in  these  cases  at  a 
lower  temperature,  generally  about  95°  F.,  and  that 
after  a  week  or  two  the  temperature  can  be  gradually 
increased.  This  'cooking  process,'  as  it  has  been 
slightingly  termed,  is  rendered  easier  by  the  use  of 
ivory  or  some  non-conducting  material  for  the  nozzle 
of  the  syringe,  since  the  patient  suffers  more  discom- 
fort from  the  heated  metal  of  the  ordinary  nozzle 
coming  in  contact  with  the  outlet  vagina  than  from 
any  degree  of  heat  in  the  water  which  it  is  advisable 
to  employ." 


—  I09  — 

The  originator's  own  words  have  been  preferably 
ly  reproduced  here  because  the  author  can  corrobo- 
rate from  personal  observation  that  here,  as  in  all 
other  hydriatic  procedures,  exact  appreciation  of  the 
technique  and  rationale  will  enable  the  practitioner 
to  obtain  the  positive  benefits  resulting  from  this 
valuable  measure. 

WATER    IN    SURGERY. 

The  most  important  advance  of  modern  times  in 
hydrotherapy,  and  one  which  has  always  been  over- 
looked or  not  credited  to  the  latter,  is  the  recognition 
of  hot  water  as  the  chief  means  of  rendering  wounds 
aseptic.  More  lives  have  been  and  will  be  saved  by 
the  appreciation  of  this  fact  than  by  any  other  con- 
nected with  this  subject.  Here,  too,  an  intelligent 
recognition  of  the  principle  involved  (cleanliness)  will 
lead  to  success.  It  will  afford  at  once  a  conception 
of  the  importance  of  the  method  if  we  briefly  com- 
pare that  now  in  vogue  with  that  of  the  past.  We 
need  not  go  very  far  back  for  the  reason.  During 
the  late  civil  war  between  the  States  water  was  a 
prominent  element  m  surgical  practice.  My  personal 
experience,  as  a  regimental,  field,  and  hospital  surgeon, 
was  as  follows:  All  wounds  were  cleansed  with  cold 
(rarely  warm)  water,  conveyed  by  sponges;  com- 
presses of  patent  lint,  moistened  with  cold  water, 
were  applied,  and  these  were  carefully  held  in  posi- 
tion by  bandages  and  moistened  from  time  to  time. 


—    no   

As  soon  as  suppuration  commenced  the  wounds  were 
sponged  and  syringed  with  warm  water,  and  the  dress- 
ings were  kept  moist  with  cold  water.  That  many 
wounded  recovered  under  this  treatment  is  true,  but 
that  it  was  an  improper  method  the  frequent  active 
and  exhausting  suppuration,  the  not  infrequent  ac- 
cumulation of  maggots,  the  common  complications  of 
erysipelas,  septicaemia,  and  gangrene,  and  the  com- 
parative immunity  from  these  undesirable  complica- 
tions under  the  modern  dry  treatment  of  wounds, 
amply  demonstrate.  The  modern  idea  would  elimi- 
nate water  from  the  treatment  of  most  wounds.  Dur- 
ing amputations,  resections,  and  other  operations,  cold 
water  was  freely  poured  over  the  field  of  operations 
by  means  of  large  sponges.  How  much  more  gentle 
is  the  modern  method  of  irrigatifig  the  exposed  struc- 
tures; how  much  more  effective  in  reaching  every 
nook  and  recess  of  the  wound,  which  would  escape 
the  sponge  or  require  its  rude  application!  But  there 
is  still  room  for  improvement  in  our  boasted  modern 
management  during  operations.  It  appears  to  me 
that  the  temperature  of  the  irrigating  fluid  should 
approximate  that  of  the  body,  and  not  be  obtained 
from  a  cold  bottle.  The  same  principle  which  de- 
mands warm  water  for  laparotomy  should  apply  to 
the  less  sensitive,  but  certainly  not  callous,  parts  in- 
volved in  amputations. 

It  is  one  of  the  triumphs  of  water  in  modern  sur- 
gery that  experience  has  demonstrated  the  value  of 
boiled  water  as  an  antiseptic  in  laparotomy. 


HOT    WATER    THE    BEST    ASEPTIC    AGENT. 

The  conviction  is  slowly  gaining  upon  the  sur- 
gical mind  that  the  various  medications  resorted  to, 
to  render  water  aseptic,  would  become  unnecessary  if 
the  proper  preparation  of  the  water  and  the  proper 
temperature  during  its  application  were  scrupulously 
attended  to.  Here  the  temperature  of  the  water  is 
an  element  of  such  decided  import  that  it  must  be 
evident  to  the  most  superficial  observer. 

HOT    WATER    AS    A    STYPTIC,    ETC. 

The  application  of  hot  water  as  a  styptic  and  to 
prevent  shock  is  of  modern  origin,  and  need  only  be 
referred  to  here  to  demonstrate  the  enormous  and 
formerly  disregarded  value  of  this  purely  hydriatic 
measure.  In  post-partum  haemorrhage  intra-uterine 
injections  with  plain  hot  water  are  our  chief  reliance. 
They  leave  the  uterus  in  an  aseptic  condition,  which 
contrasts  favorably  with  that  remaining  after  the 
formerly  vaunted  persulphate  of  iron  injection.  In 
the  former  case  the  uterus  is  left  clean  and  free  from 
coagula,  while  in  the  latter  it  is  filled  with  firm  clots, 
whose  removal  must  be  accomplished  by  processes 
that  may  produce  septic  conditions. 

The  improvement  of  modern  wound  treatment  is 
not  due  so  much  to  the  appreciation  of  certain  anti- 
septics, as  to  the  proper  application  of  water  as  a 
cleansing  agent  before  and  during  operations,  and, 
what  is  equally  as  important,  the  abolition  of  its  abuse 


—     112    

after  operations.  The  correct  appreciation  of  the  true 
functions  of  water  in  surgery,  aided  by  the  prolonged 
rest  of  the  wound  from  the  disturbances  hitherto 
practiced,  by  repeated  cleansings  and  ablutions — a 
rest  which  is  provided  by  permanent  dry  antiseptic 
dressings — these  are  the  true  causes  of  the  enormous 
reduction  of  mortality  from  wounds  in  recent  times. 
This  fact,  daily  emphasized  by  clinical  experience, 
cannot  be  too  energetically  inculcated  into  the  mind  of 
the  profession,  especially  of  its  younger  members, 
since  the  idea  seems  to  dominate  many  that  if  corro- 
sive sublimate,  carbolic  acid,  or  other  antiseptic  be 
applied  in  proper  solution  to  wounds,  all  indications 
have  been  fulfilled.  I  hold  that  thorough  cleaning 
of  the  field  of  operations  by  hot  water  and  soap, 
and  thorough  irrigation  of  the  wounded  surface — in 
other  words,  strict  cleanliness  enforced  by  the  abun- 
dance of  hot  water  used  without  stint — will  be  the  sur- 
gical antiseptic  of  the  future.  Then  cleanliness  will 
indeed  lead  to  godliness,  for  it  is  godly  to  succor  suf- 
fering humanity. 

CONTRA-INDICATIONS    TO    THE    USE    OF    WATER. 

It  is  important  to  point  out  that  water,  like  every 
other  therapeutic  agent  of  potent  action,  should  be 
used  with  caution.  Not  only,  as  has  been  pointed 
out,  is  it  imperative  to  adhere  closely  to  a  precise 
technique  and  to  understand  its  rationale,  but  even 
the   simple   application    of   water   may   prove    detri- 


~  113  — 

mental.  In  eczema,  for  instance,  it  is  now  a  recog- 
nized principle  to  abstain  from  the  use  of  water  alto- 
gether. Formerly,  bathing  an  eczematous  surface 
was  regarded  as  a  sine  qua  non  of  the  therapy  of  this 
disease. 

That  this  is  an  error,  personal  experience  has 
again  and  again  demonstrated.  I  well  remember  a 
young  colleague  who  suffered  from  a  chronic  eczema 
of  the  hands,  for  which  he  had  been  unsuccessfully 
treated  secundum  artem  by  zinc,  tar,  and  other  oint- 
ments, and  rubber  gloves.  The  suggestion  to  refrain 
from  washing  the  parts  led  to  an  early  recovery. 
Many  instances  of  a  similar  kind  have"  come  under 
my  observation.  I  refer  to  this  apparently  trivial  point 
especially  because  it  is  a  modern  observation  of  which 
personal  cognizance  extends  only  to  about  six  years, 
and  from  which  I  have  derived  more  satisfaction  than 
from  all  other  so-called  improvements  in  treatment  of 
chronic  eczema. 

IN    OTITIS    MEDIA. 

Another  contra-indication  may  be  found  in  the 
frequent  injection  of  warm  water  in  chronic  suppurat- 
ing otitis  media.  Numbers  of  observations,  made 
when  in  charge  of  the  eye  and  ear  classes  of  two  of 
our  dispensaries  some  years  ago,  have  convinced  me 
that  this  is  a  practice  which  often  maintains  the  sup- 
puration, macerating  the  inflamed  and,  sometimes, 
fungoid  edges  of  the  perforation,  and  proving  a  seri- 
ous obstacle  to  recovery.    The  simple  refraining  from 

S  EEE 


—     IT4    — 

injections  and  the  substitution  of  the  dry  boracic  acid 
treatment  have  afforded  me  brilliant  results  in  the 
most  obstinate  cases.  This  was  well  illustrated  in  a 
lady  who,  in  early  life,  had  been  a  patient  of  Politzer, 
but  had  been  later  under  simultaneous  treatment  by  an 
eminent  laryngologist  and  an  otologist  of  New  York. 
The  discharge  was  offensive  and  profuse,  and  had 
on  this  occasion  been  constant  for  six  years.  The 
syringe  had  been  faithfully  used  to  prevent  unpleasant 
odor  and  check  the  suppurative  process.  The  entire 
cessation  of  the  ulceration,  treated  with  dry  boracic 
acid  packing,  established  a  complete  cure  in  a  few 
days. 

IN    NORMAL    PUERPERAL    CONDITION. 

A  third  contraindication  to  the  local  use  of 
water,  which  I  am  glad  to  have  been  instrumental  in 
enforcing  several  years  ago,  is  the  injection  of  warm 
water,  with  and  without  antiseptics,  after  normal  labor. 
Valuable  as  this  measure  is  after  the  comparatively 
rare  abnormal  labors  when  it  is  probable  that  septic 
material  has  been  introduced  by  the  frequent  exam- 
inations or  by  instruments,  or  may  have  been  formed 
by  decomposition  of  bruised  and  decaying  tissues  or 
retained  secundines,  absteiition  from  these  injections 
after  norjnal  labors  should  be  the  first  rule  of  man- 
agement of  the  puerpera. 

In  several  papers  before  our  medical  societies  I 
have  offered  practical  facts,  not  theoretical  arguments, 
to  demonstrate  that  vaginal  injections  after  normal 


—  115  — 

labor  and  in  the  normal  puerperal  period  are  not  only 
devoid  of  value  as  a  prophylactic  measure,  but  that 
they  may  prove  a  veritable  Trojan  horse,  admitting 
the  enemy,  to  whom  we  are  energetically  striving  to 
deny  entrance,  into  the  precincts  of  the  vagina,  and 
thus  letting  loose  the  destructive  elements  among  the 
torn  and  raw  surfaces  which  expose  the  lymphatics. 
That  this  warning  is  not  out  of  place,  even  at  the 
present  day,  is  evidenced  by  the  fact  that  in  the  Lon- 
don Lancet  of  January  21,  1891,  an  article  appeared 
from  the  pen  of  one  of  the  physicians  to  the  Rotunda 
Hospital,  warmly  advocating  the  washing  out  of  the 
uterine  cavity  with  hot  water  as  a  routine  treatment 
in  private  and  hospital  practice.  Coming  from  the 
school  which  first  taught  that  ''meddlesome  mid- 
wifery is  bad  "  with  regard  to  instrumental  labors, 
such  dangerous  interference  is,  to  say  the  least, 
singular  at  a  time  when  modern  obstetrical  art  applies 
it  not  only  to  instruments,  but  even  goes  so  far  as  to 
eschew  digital  examinations.  (Leopold,  of  Dresden, 
forbids  these  to  the  students,  in  order  to  favor  asepsis 
of  the  vagina.)  Hence  the  author  is  warranted  in 
entering  the  contra  indication  to  the  use  of  water  in 
this  treatise  upon  water  in  general,  viz.,  to  abstain  from 
its  introduction  into  the  vagina  after  normal  labors. 

It  is  as  important  to  know  how  and  when  7iot  to 
use  water  as  how  and  when  to  use  it,  because,  as  will 
frequently  appear,  water  is  powerful  for  evil  as  well 
as  for  good. 


REVOLUTION  IN 

IRON  ADMINISTRATION 

A  HIGHLY  PALATABLE  PREPARATION  OF  IRON 
CHLORIDE. 


IRON  is  easily  chief  among  Hsematinics.  According-  to  T- 
Lauder  Brunton,  M.D.,  D.Sc,  F.R.S.,it  increases  the  num- 
ber of  blood  corpuscles;  the  percentage  of  haemaglobin  in 
them,  and  functional  activity  of  all  the  vital  organs;  as  a 
vascular  tonic  classes  with  digitalis  and  strychnine,  and  in  its 
alterative  qualities  with  arsenic. 

The  Tincture  of  Chloride  of  Iron  has  long  been  recog- 
nized as  the  most  efficient  of  iron  preparations,  the  objections 
to  its  continued  administration,  its  highly  astringent  taste,  its 
corrosive  action  on  the  teeth,  and  constipating  action  have, 
however,  been  hitherto  insurmountable. 

We  have  succeeded  in  preparing  an  entirely  palatable 
syrup  of  officinal  Tincture  Iron  Chloride  combining  all  its 
virtues  with  none  of  its  drawbacks.  It  is  prepared  after  the 
formula  of  Dr.  G.  W.  Weld,  and  is  entitled: 

^WELD'S  SYRUP  OF  IRON  CHLORIDE." 

(P.,  D.  &i  CO.'S) 

We  earnestly  recommend  its  trial  to  all  the  profession,  be- 
lieving it  to  be  the  most  acceptable  preparation  of  iron  ever 
devised. 

Samples  will  be  sent  on  receipt  of  request  to  physicians 
who  indicate  their  willingness  to  pay  express  charges. 


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SERIES  I. 


inhalers.  Inhalations  and  Inhalants. 
By  Beverley  Robinson,  M.  D. 

The  Use  of  Electricity  in  the  Removal  of 
Superfluous  Hair  and  the  Treatment  of 
Various  Facial  Blemishes. 
By  Geo.  Henry  Fox,  M.  D. 
New  Medications,  Vol.  t. 

By  Dujardin-Beaumetz,  M.  D. 

New  Medicationsi  Vol.  11. 

By  Dujardin-Beaumetz,  M.  D. 

The  Modern  Treatment  of  Ear  Diseases. 
By  Samuel  Sexton,  M.  D. 

The  Modern  Treatment  of  Eczema. 
By  Henr>-  G.  Piffard,  M.  D. 


intiseptic  Midwifery. 
By  Henry  J.  Gan 


larrigues,  M.  D. 
On  the  Determination  of  the  Necessity  for 
Wearing  Glasses. 

By  D.  B.  St.  John  Roosa,  M.  D. 
The  Physiological, Pathological  and  Ther- 
apeutic Effects  of  Compressed  Air. 
By  Andrew  H.  Smith,  M.  D. 
GranularLids  and  ContagiousOphthalmia. 

By  W.  F.  Mittendorf,  M.  D. 
Practical  Bacteriology. 

ByThomas  E.  Satterthwaile,  M    D . 
Pregnancy,    Parturition,    the     Puerperal 
State  and  their  Complications. 
By  Paul  F.  Mundi,  M.  D. 


SERIES   II. 


The  Diagnosis  and  Treatment  of  Haem- 
orrhoids 

By  Chas.  B.  Kelsey,  M.  D. 
Diseases  of  the  Heart,  Vol.  I. 

By  Dujardin-Beaumetz,  M.  D. 
Diseases  of  the  Heart,  Vol.  11. 

By  Dujardir-Beaumetz.  M.  D. 
The  Modern  Treatment  of  Diarrhoea  and 
Dysentery. 

By  A.  B.   Palmer,  M.  D. 
IntestinaK Diseases  o«  Children,  Vol.  I. 

By  A.  Jacobi,  M.  D. 
Intestinal  Diseases  of  Children,  Vol.  II. 

By  A.  Jacobi.  M.  U. 


The  Modern  Treatment  of  Headaches. 
By  Allan  McLane  Hamilton,  M.  D. 

The  Modern  Treatment  of  Pleurisy  and 
Pneumonia. 

By  G.  M.  Garland,  M.  D, 
Diseases  of  the  Male  Urethra. 

By  Fessenden  N.  Otis,  M.  D. 
The  Disorders  of  Menstruation. 

By  Edward  W.   Jenks,  M.  D. 
The  infectious  Diseases,  Vol.  t. 

By  Karl  Liebermeister. 

The  Infectious  Diseases,  Vol.  II. 
By  Karl  Liebermeister. 


SERIES   III. 


Abdominal  Surgery. 

By  Hal  C.  Wyman,  M.  D. 

Diseases  of  the  Liver 

By  Dujardin-Beaumetz,  M.  D. 

Hysteria  and  Epilepsy. 

By  J.  Leonard  Corning,  M.  D. 

Diseases  of  the  Kidney. 

By  Dujardin-Beaumetz,  M.  D. 

The  Theory  and  Practice  of  the  Ophthal- 
moscope. 

By  J.  Herbert  Claiborne,  Jr.,  M.  D. 

Modern  Treatment  of  Bright's  Disease. 
By  Alfred  L.  Loomis,  M.  D. 


Clinical  Lectures  on  Certain  Diseases  of 
Nervous  System. 

By  Prof.  J.  M.  Charcot,  M.  D. 
The  Radical  Cure  of  Hernia. 

By  Henrv  O.  Marcy,  A.  M.,  M.  D., 
L.  L    D. 
Spinal  Irritati'-n. 

By  William  A.  Hammond,  M.  D. 
Dyspepsia. 

By  Frank  Woodbury,  M.  D. 
The  Treatment  of  the  Morphia  Habit. 

By  Erlenmeyer. 
The  Etiology,  Diagnosis  and  Therapy  of 
Tuberculosis. 

By  Prof.  H.  von  Ziemssen. 


SERIES   IV. 


Nervous  Syphilis. 

By  H.  C.  Wood,  M.  D. 
Education  and   Culture  as  correlated  to 
the  Health  and  Diseases  of  Women. 
By  A.  J.  C.  Skene,  M.  D. 

Diabetes.  .,    ^ 

By  A.  H.  Smith,  M    D. 

A  Treatise  on  Fractures. 

By  \rmand  Despres,  M.  D. 
Some  Majorand  Minor  Fallacies  concern- 
ing Syphilis. 

By  E.  L.  Keyes,  M  .D. 
Hypodermic  Medication. 

By  Bourneviile  and  Bricon. 


Practical    Points   in  the  Management  of 
Diseases  of  Children. 
By  L  N.  Love,  M.  D. 

Neuralgia. 

By  E.  P.  Hurd,  M.  D. 

Rheumatism  and  Gout. 

By  F.  Le  Roy  Satterlee,  M.  D. 
Electricity,  Its  Application  in  Med'cme. 

By  Wellington  Adams,  M.D.     [Vol.1] 
Electricity,  Its  Application  In  Medicne. 

By  Weli-gton  Adams,  M.D.  [Vol.11] 
Auscultation  and  Percussion. 

■  Hy  Frederick  C.  Shattuck,  M.  D. 


SERIES   V. 


Taking  Cold. 

By  F.  H.  Bosworth,  M.  D. 

Practical  Notes  on  Urinary  Analysis. 
By  William  B.  Canfield,  M.  D. 

Practical  Intestinal  Surgery.    Vol.1. 

Practical  Intestinal  Surgery.    Vol.11. 

By  F.  B.  Robinson,  M.  D. 

Lectures  on  Tumors. 

By  John  B.  Hamilton,  M.  D.,  LL.  D. 

Pulmonary  Consumption,  a  Nervous  Dis- 
ease. 

By  Thomas  J .  Mays,  M .  D . 


Artificial  Anaesthetics  and  Anaesthesia. 
By  DeForest  Willard,M.  D.,and  Dr. 
Lewis  H.  Adler,  Jr. 

Lessons  in  the  Diagnosisand  Treatment 
of  Eye  Diseases. 

By  Casey  A.  Wood,  M.  D. 

The  Modern  Treatment  of  Hip  Disease. 
By  Charles  F.  Stillman,  M.  D. 

Diseases  of  the  Bladder  and  Prostate. 
By  HalC.  Wyman,  M.  D. 

Cancer. 

By  Daniel  Lewis,  M.  D. 
Insomnia  and  Hypnotics. 

By  Germain  See. 

Translated  by  E.  P.  Hurd,  M.  D. 


The  Uses  of  Water  in  Modern  Medicine. 
VoLI. 


SERIES   VI.* 

Gonorrhoea  and  Its  Treatment. 
By  G.  Frank  Lydston,  M.  D. 


The  Uses  of  Water  in  Modern  Medicine. 
Vol.  n. 
By  Simon  Barucb,  M.  D. 

The  Electro-Therapeutics  of  Gynaecol- 
ogy. Vol.  I. 

The  Electro-Therapeutics  of  Gynaecol- 
ogy. Vol.  II. 

By  A.  H.  Goelet,  M    D. 

Cerebral  Meningitis. 

By  Martin  W.  Barr,  M.  D. 

Contributions  of   Physicians  to    English 
and  American  Literature. 
By  Robert  C.  Kenner,  M .  D . 


Acne  and  Alopecia. 

By  L.  Duncan  Bulkley,  M.  D. 

Sexual  Weakness  and  Impotence. 
By  Edward  Martin,  M.  D. 

Fissure  of  the  Anus  and  Fistula  in  Ano 
By  Dr.  Lewis  H.  Adler,  Jr. 

Modern  Minor  Surgical  Gynaecology. 
By  Edward  W.  Jenks,  M.  D. 

The  Use  of  the  Laryngoscope. 
By  J.  Solis  Cohen,  M.  D. 


*  To  be  issued  one  a  month  during  1892. 


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A  NEW  TREATMENT  OF  CHRONIC  METRITIS 50 

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By  Dujardin-Beaumetz,  M.  D. 

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